Voriconazole-Associated Periostitis in a Heart Transplant Patient

A 60 year-old female with a history of a heart transplant was treated with voriconazole for presumed pulmonary aspergillosis. After approximately three months, she began to experience progressively worsening musculoskeletal pain. Her presentation was notable for widespread tenderness, a lack of digital clubbing, and elevated alkaline phosphatase. Bone scintigraphy demonstrated increased activity at multiple locations correlating with the patient’s pain. Periostitis was identified in these locations on radiographs. A few months after discontinuing voriconazole, the patient’s pain had resolved, alkaline phosphatase had normalized, and abnormal activity on scintigraphy had markedly improved.