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Musculoskeletal Imaging

E2670. Spectrum of Voriconazole-Associated Periostitis

Tan I1,  Lomasney L2,  Stacy S3,  Lazarus M4,  Winnie M.1 1. University of Illinois at Chicago, Chicago, IL; 2. Loyola University, Chicago, IL; 3. University of Chicago, Chicago, IL; 4. Northshore Medical Group, Chicago, IL

Address correspondence to W. Mar (

Background Information: Voriconazole-induced periostitis is a relatively newly described entity resulting in diffuse bone pain and often widespread periostitis. We present a multimodality review, including on body CT, to increase radiologist awareness of this entity.

Educational Goals/Teaching Points: We describe the pathophysiology and imaging findings of voriconazole-induced periostitis. Learners will recognize the need to correlate for history of treatment with voriconazole, typically in immunosuppressed patients with cancer or transplant. We review other etiologies in the differential diagnosis, including hypertrophic osteoarthropathy, venous stasis, pachydermoperiostitis, and thyroid acropachy.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: Voriconazole contains a relatively large amount of fluoride. Long-term use may result in subacute fluoride poisoning accompanied by pain and periostitis. A high serum fluoride level is commonly found. The periostitis appears more nodular, dense, and irregular compared to periostitis seen in other entities in the differential diagnoses. Symptoms typically resolve after cessation of the medication.

Conclusion: Voriconazole-induced periostitis is important to recognize as patients develop rapid pain relief with cessation of voriconazole treatment.