(Kiosk 1) Rehabilitation Following Voriconazole Associated Periostitis

Case Diagnosis: 34-year-old male with Granulomatosis with Polyangiitis admitted to inpatient rehabilitation with voriconazole associated periostitis

Case Description or Program Description: 34-year-old male with history of Granulomatosis with Polyangiitis complicated by diffuse alveolar hemorrhage and persistent pulmonary aspergillosis on chronic voriconazole status post bilateral orthotopic lung transplant 12 months prior to presentation who presented to inpatient rehabilitation (AIR) following progressive functional decline. He was initially admitted to the acute care facility with one month of worsening fatigue, generalized weakness, and diffuse body pain. Given his severe bone pain affecting multiple sites, elevated alkaline phosphatase level and radiographic evidence of proliferative osteoarthropathy, he was diagnosed with voriconazole-induced periostitis. Voriconazole was promptly discontinued and replaced by Posaconazole and he was subsequently admitted to inpatient rehabilitation.

Setting: Inpatient Rehabilitation

Assessment/Results: This patient was previously independent for ADLs and mobility, however, demonstrated progressive functional decline related to pain and deconditioning from periostitis and was requiring assistance with activities of daily living (ADLs) and mobility. His pain symptoms began to improve within 72 hours of Voriconazole discontinuation. During his inpatient rehabilitation course, pain was controlled by a multi-modal approach with Venlafaxine, Gabapentin, and low-dose hydrocodone/acetaminophen as needed. Approximately 4 weeks after cessation of Voriconazole, the patient no longer endorsed any bony pain and had returned to his functional baseline. At time of discharge from inpatient rehabilitation he was independent for ADLs and mobility.

Discussion (relevance): Voriconazole associated periostitis is a rare cause of diffuse bony pain associated with long term voriconazole use. Presentation typically includes bone pain, dental fluorosis and high alkaline phosphatase levels. Bones affected include proximal long bones, ribs, clavicle, hands, and acetabulum. Treatment includes discontinuation of affecting agent. This case presentation demonstrates successful rehabilitation following diagnosis and voriconazole discontinuation.

Conclusions: Voriconazole associated periostitis is rare, debilitating condition. With appropriate diagnosis, treatment and rehabilitation, these patients can make significant gains and return to functional baseline.