Mimicking Multiple Myeloma: Voriconazole-Induced Hyperfluorosis and Bone Lesions

  • Kristen D. KelleyEmail author
  • George R. Thompson
  • Paul Aronowitz
Clinical Image
A 70-year-old man was found to have diffuse lytic and sclerotic bone lesions during a work-up to rule out malignancy after sustaining an unprovoked pulmonary embolus (Fig. 1). The patient reported several months of deep “bone pain” and debilitating weakness. Past medical history was significant for a history of disseminated coccidioidomycosis for which he was being treated with voriconazole. An extensive work-up, including biopsy of a bone lesion, bone marrow biopsy, and protein electrophoresis, was unrevealing. Due to an elevated alkaline phosphatase level in the setting of chronic voriconazole use, a fluoride level was checked and found to be markedly elevated at 16 mmol/L (normal 1–4 mmol/L).
Figure 1

Radiograph of the left humerus showing diffuse lytic lesions (a) and extensive endosteal scalloping (b).

Voriconazole is one of the triazoles, which are the mainstay of therapy for disseminated coccidioidomycosis infections. Chronic voriconazole use has been associated with elevated serum levels of fluoride and skeletal disease. Bony changes resemble periostitis deformans, a condition associated with drinking excessively fluoridated water1, 2, 3. Additionally, voriconazole is believed to cause bony changes in a non-fluoride mediated pathway via osteoblast activation and stimulation of cytokine release4. In our patient, voriconazole was replaced with posaconazole and he experienced significant improvement within weeks of this change.


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Conflict of Interest

The authors have no conflicts of interest to disclose and have received no financial support for this project.


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Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  1. 1.Department of Internal MedicineUC DavisSacramentoUSA
  2. 2.Department of Internal Medicine, Division of Infectious DiseaseUC DavisSacramentoUSA

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