病史
A 59-year-old man underwent double lung transplant for idiopathic pulmonary fibrosis, which was complicated by bronchiolitis obliterans and fungal superinfection. One year later he was started on voriconazole suppressive therapy. During the next few years he began to complain of gradually worsening neck/back pain.
59岁男性，5年前因特发性肺纤维化行双侧肺移植手术，术后合并闭塞性细支气管炎和真菌感染。一年后，开始使用伏立康唑（voriconazole，抗真菌药）治疗，随后出现颈背部疼痛，并逐渐加重。
图例Representative noncontrast chest CT, sagittal reconstruction (A), obtained 4 years after initiation of voriconazole therapy demonstrates progressive flowing periosteal sternomanubrial and paravertebral (green arrows) calcifications. Concurrent axial noncontrast chest CT (B) after 4 years of antifungal therapy demonstrates the nodular and thick lamellar periosteal calcific changes within the thoracic spine (yellow arrow) and, additionally, involving the visualized ribs (green arrows) and inferior scapulae (red arrow). AP chest radiograph (C), 4 years posttherapy with voriconazole, demonstrates thick lamellar and nodular periosteal calcification involving the visualized ribs (green arrows), scapulae (yellow arrow), clavicles (red arrow), and proximal humeral shafts (blue arrow).
4年前最初使用伏立康唑治疗时，CT平扫矢状位重建显示：胸骨柄（红箭头）及椎体旁线样钙化（绿箭头）。
抗真菌治疗4年后，胸部平扫示胸椎周围骨膜结节状及厚层状钙化（黄箭头），另外可见肋骨（绿箭头）和肩胛骨（红箭头）受累。
胸部正位片示肋骨（绿箭头）、肩胛骨（黄箭头）、锁骨（红箭头）、股骨近端（蓝箭头）骨膜呈厚层状及结节状钙化。
Drug-Induced Chronic Hyperfluorosis药物相关性慢性氟中毒
背景Voriconazole, a second generation fluorinated antifungal agent, is commonly used for treatment of fungal pathogens in immunocompromised patients.伏立康唑是第二代含氟抗真菌药，广泛应用于免疫功能不全患者的抗真菌感染治疗。
临床印象Double lung transplant complicated by fungal superinfection started on voriconazole双肺移植术后，合并反复真菌感染，应用伏立康唑治疗。
影像诊断要点
- Progressive development of thick lamellated periosteal calcifications involving the axial and appendicular skeleton中轴骨及四肢骨骨膜周围的厚层状钙化，并渐进性加重
- History of long-term antifungal use长期抗真菌药物应用
- Often associated with painful periostitis, which can be a useful clue to help differentiate hyperfluorosis from DISH, which is usually indolent.多合并骨膜炎并伴有疼痛。是否有疼痛症状是氟中毒与DISH（弥漫性特发性骨肥厚症）的主要鉴别点，后者一般无疼痛。
鉴别诊断
- Primary/secondary hypertrophic osteoarthropathy原发/继发性肥厚性骨关节炎
- Hematopoetic malignancies (eg, leukemia)造血系统恶性肿瘤（例如：白血病）
- Diffuse idiopathic skeletal hyperostosis弥漫性特发性骨肥厚症
- Ankylosing spondylitis强直性脊柱炎
- Psoriatic or reactive (Reiter) arthritis银屑病关节炎或Reiter综合征
治疗
- Conservative management保守治疗
- Osteophyte resection can be considered if symptomatic如果有症状，可以考虑骨赘切除术