A 51-year-old woman presented with a 1-month history of intense and worsening polyarthralgia and swelling of bilateral fingers and toes. There was no history of alopecia, oral ulcers, rashes, or Raynaud phenomenon. She did not report preceding fever, diarrhea, or dysuria. There was no history of weight loss or anorexia. Medical history included tertiary hyperparathyroidism related to end-stage kidney disease from chronic glomerulonephritis. The patient had successfully received an ABO-incompatible kidney transplant 1 year ago, but this was complicated by invasive fungal (Volvariella volvacea) infection of the central nervous system. Medications included tacrolimus (0.5 mg twice daily), prednisolone (10 mg daily), cinacalcet (12.5 mg daily), and voriconazole (500 mg daily). On examination, her fingers and toes were symmetrically and diffusely swollen and tender. There was no rash, enthesitis, psoriatic nail changes, clubbing, or lower limb edema. The rest of the physical examination was unremarkable.
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D. Stop voriconazole
The key to the correct diagnosis in this case is the radiographic appearance of periostitis (defined as inflammation of the connective tissue surrounding bone) in the setting of chronic voriconazole use and a high alkaline phosphatase level. Hypertrophic osteoarthropathy is an unlikely cause of the periostitis, given the absence of clubbing or clinical suggestion of malignancy. Therefore, a positron emission computed tomography scan (choice A) to assess for occult malignancy would not be appropriate. A bone biopsy (choice B) may aggravate the periostitis and would likely reveal nonspecific osteoblastic proliferation and reactive new bone formation—changes that would not discriminate between the causes of periostitis.1 While hyperparathyroidism may cause subperiosteal resorption and pseudoperiostitis, pain and florid new bone formation visible on the hand radiograph cannot be attributed to hyperparathyroidism. Therefore, parathyroidectomy (choice C) is not appropriate.
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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.
Corresponding Author: Jiacai Cho, MBBS, MMed, Division of Rheumatology, Department of Medicine, National University Hospital, Singapore, 1E Kent Ridge Rd, Level 10, NUHS Tower Block, Singapore 119228 (email@example.com).
Published Online: December 16, 2021. doi:10.1001/jama.2021.18866
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank Vincent Tiong Tze Yang, MBChB, MMed (Department of Diagnostic Radiology, National University Health System, Singapore), for helping us acquire the images for this article; he received no compensation for his contributions. We thank the patient for providing permission to share her information.
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