Voriconazole-induced Periostitis
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"CASE: A woman in her 60s presented with complaints of severe multifocal bone pain, including the shoulders, sternum, and hips, which had persisted for several months. Two years earlier, the patient had undergone heart transplant for ischemic cardiomyopathy. She had a history of post-transplant AKI on CKD, hypertension, hyperlipidemia, osteoporosis, hypothyroidism and COPD. She was on maintenance immunosuppression with azathioprine, tacrolimus and prednisone. She was on voriconazole for chronic suppression of Bipolaris sp. mediastinitis diagnosed shortly after transplantation and had remained on the antifungal. The patient reported bone pain and a lump on the left clavicle that was palpable on physical examination. Radiograph of the left clavicle can be seen below (Figure 1). Laboratory values demonstrated an elevated creatinine (2.28mg/dL), BUN (35 mg/dL), TSH (2.77 mcunit/mL), alkaline phosphatase (616 units/L), ALT (62 units/L), and AST (67 units/L).
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