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case_images: Pelvic radiography and bone scintigraphy. A, Pelvic radiography: pseudofracture of bones (Looser zone) are shown by yellow circles and a yellow arrow. B, Bone scintigraphy: There are multiple uptakes throughout the skeletal system.
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case_images: Pelvic radiography showed Looser zone reflecting pseudofractures (Fig. 1A). Whole-body bone scintigraphy revealed multiple fractures of the cranial bone, scapula, ribs, radial bone, spine, pelvis, and tibia (Fig. 1B).
case_images: 111In-pentetreotide scintigraphy and MR imaging. A, 111In-pentetreotide scintigraphy: A subtle uptake in the midline of the head (blue arrow). B, MR imaging: Mass-like lesions at posterior ethmoidal sinus with low signal intensity in both T1- and T2- weighted images (yellow arrows).
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case_images: We diagnosed FGF23-related hypophosphatemic osteomalacia based on the following diagnostic criteria for osteomalacia: hypophosphatemia, elevated serum ALP levels, symptoms of bone pain, low bone mineral density, multiple uptakes in bone scintigraphy, and radiography findings of Looser zone. 111In-pentetreotide scintigraphy performed to localize the tumor showed subtle uptake in the midline of the head (Fig. 2A). T1- and T2- weighted images. These findings were nonspecific but appeared to be inflammation or edema of the nasal mucosa (Fig. 2B).
case_images: Systemic venous sampling of FGF23. Serum FGF23 levels (pg/mL) with the corresponding venous names; the highest being in the left common iliac vein, 270 pg/mL.. Abbreviations: AV, axillary vein; BV, brachiocephalic vein; CIV, common iliac vein; FV, facial vein; IJV, internal jugular vein; IVC, inferior vena cava; lt., left; Rt., right; SV, subclavian vein; SVC, superior vena cava.
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case_images: SVS of FGF23 to confirm the origin of FGF23 secretion. Surprisingly, serum FGF23 concentration was the highest in the left common iliac vein with 270 pg/mL (Fig. 3).
case_images: 68Ga-DOTATOC PET/CT and pelvic CT and MR imaging. A, 68Ga-DOTATOC PET/CT: focal uptake in the left anterior inferior iliac spine (yellow arrow) clearly demonstrating the tumor location. B, CT imaging: A high-density area in the left anterior inferior iliac spine (yellow arrow). C, MR imaging: A high signal intensity of the left anterior inferior iliac spine on short tau inversion recovery image (yellow arrow).
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case_images: The 68Ga-DOTATOC PET/CT clearly demonstrated focal uptake in the left anterior inferior iliac spine (Fig. 4A). Although a high-density area in the CT scan and a high intensity area in MR images were shown in the left anterior inferior iliac spine (Fig. 4B and C), these findings were not specific enough to detect the location of tumor.