Author(s)

Monica Sircar¹, Camille Kotton², David Wojciechowski^1,3, Kassem Safa^1,3, Hannah Gilligan^1,3, Eliot Heher^1,3, Winfred Williams^1,3, Ravi Thadhani¹, Nina Tolkoff-Rubin^1,3

¹Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
²Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
³MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA.

Background: Voriconazole is frequently used to treat fungal infections in solid organ transplant patients. Recently, there have been reports suggesting that prolonged voriconazole therapy may lead to periostitis. Aim: Here we present two cases of voriconazole-induced periostitis in solid organ transplant patients. Case Presentation: Voriconazole was given to two transplant patients-one with a liver transplant and the second with a heart transplant, to treat their fungal infections. Both developed voriconazole-induced toxicity. While undergoing voriconazole therapy, they had incapacitating bone pain. The liver transplant patient had to be taken off voriconazole, and the heart transplant patient succumbed to non-voriconazole related causes. Conclusions: Voriconazole therapy in two solid organ transplant patients resulted in periostitis. We provide potential etiologies underlying voriconazole-induced periostitis, including fluoride toxicity, abnormalities in the pulmonary vascular bed leading to the production of downstream inflammatory mediators, and abnormal pharmacokinetics of hepatic drug metabolism. In addition to monitoring blood voriconazole trough levels, we suggest careful assessment for musculoskeletal pain in patients undergoing voriconazole treatment for two months or more, particularly if their daily dosages of voriconazole exceed 500 mg per day. Appropriate workup should include measurement of alkaline phosphatase and fluoride levels, voriconazole trough and bone scan. Overall, early recognition of voriconazole-induced musculoskeletal toxicity is important for better morbidity outcomes.

Voriconazole, Periostitis, Organ Transplant, Enthesopathy, Drug Metabolism

Sircar, M. , Kotton, C. , Wojciechowski, D. , Safa, K. , Gilligan, H. , Heher, E. , Williams, W. , Thadhani, R. and Tolkoff-Rubin, N. (2016) Voriconazole-Induced Periostitis & Enthesopathy in Solid Organ Transplant Patients: Case Reports. Journal of Biosciences and Medicines, 4, 8-17. doi: 10.4236/jbm.2016.411002.