539

Osteomalacia: Uncommon Causes

Melvin L. Turner,1 and Murray K. Dalinka1

Osteomalacia is an abnormality of bone characterized by Medical Clinic at the Hospital of the University of Pennsylvania, a

an accumulation of increasing matrix and epiphyseal carti- telangiectatic soft tissue mass was discovered on the dorsum of her
lage, which fails to calcify or does so extremely slowly. right foot. An association between soft tissue tumors and osteo-
malacia was suggested.
Diagnosis is made histologically by widened osteoid seams
Radiography of the pelvis (fig. 1) revealed bilateral ischiopubic
and is radiologically dependent upon the demonstration of
pseudofractures. Angiography of the right foot demonstrated a
looser zones or pseudofractures, [1 , 2]. Osteomalacia may
highly vascular soft tissue tumor. Bone scan revealed increased
result from various etiobogic factors that may be divided into
uptake in the spine, anterior ribs, pelvis, and right knee.
three major groups as by Mankin [3]: A biopsy of the vascular lesion revealed a cavernous heman-
1 .-Deficiency states, including primary vitamin D defi- gioma, and a below-knee amputation was performed. The bone
ciency (lack of intake or ultraviolet exposure), calcium or pain disappeared 3 days after surgery and since that time the
phosphorus deficiency, and chelators (oxalate, phosphate). patient has remained asymptomatic. The serum calcium, phospho-
2 .-Absorbtive defects, including gastric, pancreatic, in- rous, and alkaline phosphatase have returned to a normal level.
testinal, and hepatobiliary disorders, including postsurgical
defects. Case 2
3.-Renal disease, including tubular defects or renal
C. L. , a 77-year-old white man was evaluated for increasing bone
tubular acidosis from congenital abnormalities. Acquired pain and stiffness ofthe left hip. Radiography demonstrated bilateral
disease can cause renal tubular acidosis or renal osteodys- scapular (fig. 2A) and left femoral neck pseudofractures (fig. 2B)
trophy. with generalized coarsening of the bony trabecule. The patient was
Miscellaneous causes of osteomalacia include fibrous then admitted to the Hospital of the University of Pennsylvania for
dysplasia, neurofibromatosis, and osteopetrosis [4]; medi- evaluation of osteomalacia.
cation including Dilantin and phenolphthalein [5]; neo- While in the hospital, he was found to have Bence Jones protein-
plasms, both benign and malignant, of either bone or soft unia, and a bone marrow aspirate revealed 1 0% atypical plasma

tissues; and unclassified causes, including hypophospha- cells. The osteomalacia was thought to be secondary to renal

tasia, axial osteomalacia [4], fibrogenesis imperfecta os-

seum [5], and fluoride ingestion [4].
The cause of the osteomalacia is usually obvious when
the radiographs are positive; occasionally, the underlying
disorder is occult and familiarity with the various etiologies
and associated diseases may enable the radiologist to sug-
gest the correct diagnosis. Our recent experience with two
cases of osteomalacia in which the discovery of the under-
lying abnormality led to profound changes in therapy and
prognosis form the basis for this report.

Case Reports

Case
H. H. , a 56-year-old black woman, had bone pain and pseudo-
fractures. She was followed for 8 years with a diagnosis of adult
onset hypophosphatemic osteomalacia (vitamin D resistant rickets).
She was treated with calcium carbonate, phosphorous, and high Fig. 1 -Case 1 . Anteropostenior film of pelvis. Bilateral symmetrical,
doses of vitamin D with subjective benefit. As an outpatient in the pelvic pseudofractures. Contrast from previous myelography is seen.

Received January 3, 1 979; accepted after revision March 9, 1979.

I Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 1 91 04. Address reprint requests to M. K. Dalinka.

AJR 133:539-540, September 1979; 0361 -803x/79/1 333-0539 $00.00; © American Roentgen Ray Society
 540 CASE REPORTS AJR:133, September 1979

Fig. 2.-Case 2. A, Pseudofracture of right scapula. B, Coarse osseous trabeculae and pseudofracture of left femoral neck.

phosphate leak due to light chain proteinunia all caused by the temia [1 1 1 and osteomalacia. Pathologically, the majority of
plasma cell dyscrasia. He had classic Fanconi’s syndrome with patients with myeboma and osteomalacia exhibited degen-
phosphatunia, aminoacidunia, and glycosunia without hypergly- erative changes in the renal tubules, especially the proximal
cemia. The patient was placed on prednisone and Cytoxan for
convoluted tubules [1 1].
treatment of myeboma, and is currently being followed as an out-
patient.
REFERENCES

1 . Mankin HJ: Rickets, osteomalacia and renal osteodystrophy.

Discussion
Part I. J Bone Joint Surg(AmJ 56: 1 01 -1 28, 1974
In case 1 , osteomalacia was associated with a soft tissue
2. Fourman P. Royer P: Calcium Metabolism and the Bone, 2d
tumor, and removal of the tumor cured the osteomalacia.
ed. Philadelphia, Davis, 1968
This patient had been diagnosed as having adult onset 3. Mankin HJ: Rickets, osteomalacia and renal osteodystrophy.
hypophosphatemic osteomalacia (e.g. , vitamin D resistant Part II. J Bone Joint Surg[Am156:352-386, 1974
rickets) and treated as such for about 8 years. An awareness 4. Arnstein AR, Frame B, Frost HM: Recent progress in osteo-
of this cause and effect relationship would have alleviated malacia and rickets. Ann Intern Med 67 : 1 296- 1 330, 1967

years of needless therapy. As cited by Mankin [3], Prader 5. Frame B, Guiang HL, Frost HM, Reynolds WA: Osteomalacia
induced by laxative (phenolphthalein) ingestion. Arch Intern
described the relation between neoplasms and rickets in
Med 128:794-796, 1971
1 959, and since then about 30 cases have been reported
6. Frame B, Frost HM, Pak CYC, Reynolds W, Angan RG: Fibno-
[1 , 7-1 01. Most ofthe tumors described are benign, vascular
genesis imperfecta ossium, a collagen defect causing osteo-
soft tissue tumors, particularly hemangiomas and heman-
malacia. N Eng J Med 285: 769-772, 1 971
giopericytomas, but bone neoplasms such as giant cell 7. Salassa R, Jowsey J, Arnaud C: Hypophosphatemic osteoma-
tumor [2], osteoblastoma [9], and nonossifying fibroma [2] lacia associated with non-endocrine tumor. N Eng! J Med 238:
have also been reported. The mechanism of tumor-induced 65-70, 1970
osteomalacia is unknown, but is thought to be secondary to 8. Linovitz R, Resnick D, Keissling P, Kondon JJ, Sehler B, Nejdl
the excretion of a vitamin D antagonist or other humeral RJ, Rowe JH, Deftos U: Tumor induced osteomalacia and
substance by the tumor. rickets. J Bone Joint Surg [Am] 58 : 4 1 9-423, 1976

Our second patient was only mildly symptomatic and was 9. Yoshikawa S, Nakamora T, Takaci M: Benign osteoblastoma
as a cause of osteomalacia. J Bone Joint Surg [BrJ 59:279-
admitted to the hospital because of the radiographic diag-
286, 1977
nosis of osteomalacia. On evaluation he was found to have
1 0. Renton P, Shaw D: Hypophosphatemic osteomalacia second-
Fanconi’s syndrome secondary to renal tubular acidosis
ary to vascular tumors of bone and soft tissue. Skeletal Radiol
caused by the deposition of light chains in the renal tubules.
1 :21-24, 1976
The light chain deposition caused proximal renal tubular 1 1 . Maldonaro JE, Vebosa A, Kyle RA, Wagoner AD, Holley KE,
dysfunction (renal tubular acidosis type 2) with inappro- Salassa RM: Fanconi syndrome in adults. Am J Med 58:354-
priate excretion of phosphorous resulting in hypophospha- 364, 1975