Photoclinic Diagnosis: Oncogenic osteomalacia

A54-year-old male smoker presented with complaints of generalized bone and muscle pain. His pain was aggravated over time to the extent that he became unable to walk and developed paraparesis. Upon physical examination, a tumor was not located, however, generalized bony tenderness with decreased muscle strength, predominantly in the lower extremities was noted. On lung examination, bilateral scattered wheezing was heard. The patient underwent a bone scan which revealed multiple metabolically active bony lesions in the ribs (mainly in the costochondral junctions), sternum, lower cervical and thoracic spine that was suspicious for multiple bony metastases versus metabolic bone disease. Thoracolumbosacral magnetic resonance imaging (MRI) results revealed hypersignal intensity on T1 and T2 images that favored replacement of red marrow with fat. Imaging studies which included: spiral chest, abdominopelvic, and paranasal CT-scans were unremarkable.