Voriconazole-induced periostitis.

Voriconazole is a fluorinated drug from the triazole group that is widely used in the prophylaxis and treatment of fungal infections in immunosuppressed patients. Chronic use of this medication can generate, as an adverse effect, a multifocal, asymmetric, diffuse and nodular periosteal reaction, associated with severe and disabling skeletal pain and elevated alkaline phosphatase and serum fluoride. Radiography is the imaging technique of choice for periostitis diagnosis. In general, clinical manifestations and radiographic findings disappear, when the drug is discontinued. We report the clinical case of a 44 year-old woman diagnosed with acute myeloid leukemia, who developed an invasive fungal infection treated with voriconazole after a stem cell transplant. Nine months after starting antifungal treatment, she manifested symptoms and radiological signs compatible with periostitis. Due to clinical suspicion, we decided to suspend voriconazole, with consequent resolution of clinical manifestations and radiological findings.

Pain relief after total hip replacement: oral CR oxycodone plus IV paracetamol versus epidural levobupivacaine and sufentanil. A randomized controlled trial.

BACKGROUND: We tested the hypothesis that pain relief after total hip replacement (THR) can be obtained with a multimodal approach using oral controlled release (CR) oxycodone plus IV paracetamol. METHODS: Two hundred and sixty patients undergoing THR were randomized into two groups. A group of 130 patients (EPI) under epidural anesthesia followed by continuous infusion of levobupivacaine 0.125% and sufentanil 0.7 mcg/mL at 7 mL/h was compared with a group (OXY) of 130 patients under spinal anesthesia and oral CR oxycodone 10 mg/q12h plus IV paracetamol 1g/q6h. Pain intensity at rest and dynamic by visual analogue scores (VAS), rescue dose consumption and side effects of three postoperative days (POD) were collected and analyzed with Mann-Withney test (P<0.05 was considered significant). RESULTS: VAS values at rest were similar in both groups at POD#1, significantly lower in the OXY group either at POD#2 (P=0.018) and POD#3 (P=0.001). Dynamic VAS values were significantly lower in the EPI group at POD#1 (P=0.001), similar for both groups at POD#2 and significantly lower in the OXY group at POD#3 (P=0.026) than the comparing group. Rescue dose consumption was significantly lower in the EPI group during the POD#1 (P=0.009), similar for both groups at POD#2 and higher in the EPI at POD#3 (P=0.008). The incidence of vomiting was similar for the two groups. Nausea was more frequent in the OXY group at POD#3 and more hypotension events occurred in the OXY group at POD#2. CONCLUSION: Oral CR oxycodone plus IV paracetamol was as effective as epidural levobupivacaine and sufentanil for postoperative pain relief after THR.