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Clinical Images

Osteomalacia and Multiple Fractures in an Obese Young Man


Authors: Jyun-Bao Cian1, Yi-Chun Lin3,4, Hsi-Hsien Chen1,2 ,Yen-Chung Lin1,2*


            A 37 year-old male with type 2 diabetes presented with a 1-year history of intermittent chest pain. He denied chronic cough or trauma. His past surgical history was significant for laparoscopic sleeve gastrectomy for severe obesity about 2 years ago with resultant weight loss of about 40kg. He denied any past history or shortness of breath and physical examination were unremarkable. He denied any family history of bone disease.

On admission, chest X-ray showed old fractures of multiple ribs bilaterally and an old fracture of left distal clavicle (black arrow; and pseudo-fracture, white arrow in figure 1). Lumbar spine MRI revealed compression fractures at L3-L5 (white arrow, figure 2). Chest x-ray and blood phosphate level prior to sleeve gastrectomy were normal.  Bone densitometry was consistent with osteopenia (T-score: -1.86 SD). Labs done on admission showed serum Ca 8.6 mg per deciliter (normal 8.6-10.2 mg per deciliter), serum phosphate 2.6 mg per deciliter (normal 2.5-4.5 mg per deciliter), 24 hrs urine phosphate 659 mg per day (normal 400-1300 mg per day), intact PTH 71.1 pg per milliliter (normal 14-72 pg per milliliter), and TmP/GFR was 0.57 mmol per liter (normal 1.00-1.35 mmol per liter), consistent with hypophosphatemia due to renal phosphate wasting. The 25-Hydroxy Vitamin D levels were low (18 ng per milliliter); no significant urine bicarbonate levels, aminoaciduria or glucosuria were detected. Oncogenic osteomalacia was excluded by normal fibroblast growth factors 23 (FGF 23) and FDG positron emission tomography (PET/CT) scan.

Osteomalacia due to vitamin D deficiency leading to multiple rib and spinal compression fractures was diagnosed.  Therapeutic doses of active vitamin D3 and calcium carbonate were initiated and the patient recovered substantially.  Repeat phosphate levels were 3.3 mg and 4.0 mg per deciliter after 1 month and 3 months, respectively.

Figure legend:

Figure 1A: Chest X-ray showed the rib cage appears old fracture of multiple both ribs, and old fracture of left distal clavicle was also seen (black arrow; and pseudo-fracture, white arrow). Figure 1B: Previous chest X-ray appeared normal.

Figure 2: The L-spine MR image revealed compression fractures at L3-L5 (white arrow)



Which of the following is not a cause of osteomalacia?

  1. Vitamin D deficiency or Rickets
  2. Tumor
  3. Fanconi syndrome
  4. Osteoporosis

Click here to view answer


1.         Stein J, Stier C, Raab H, Weiner R. Review article: The nutritional and pharmacological consequences of obesity surgery. Alimentary pharmacology & therapeutics 2014; 40: 582-609.

2.         Oliveri B, Gomez Acotto C, Mautalen C. Osteomalacia in a patient with severe anorexia nervosa. Revue du rhumatisme 1999; 66: 505-508.

3.     Bal BS1, Finelli FC, Shope TR, Koch TR. Nutritional deficiencies after bariatric surgery. Nat Rev Endocrinol. 2012 Sep;8(9):544-56.



Author Bios

Jyun-Bao Cian is a medical student of Taipei medical university in clerkship. Yi-Chun Lin MD is a consulting visiting staff of endocrinology department of Taipei Veterans General Hospital. Yen-Chung Lin MD and Hsi-Hsien Chen MD PhD are both visiting staff of Taipei Medical University Hospital. Taipei Medical University (TMU), located in prosperous Taipei City, ranked as 398 in QS World University Rankings® 2018. TMU is also honored as top private university in Taiwan.




1Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital

2Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan

3Division of Endocrinology & Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan;

4Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan