Hypophosphatemic osteomalacia associated with tenofovir: a multidisciplinary approach is required.

Giuseppe Vittorio De Socio, Gianluigi Fabbriciani, Marco Massarotti, Salvatore Messina, Enisia Cecchini, Bianca Marasini
  • Giuseppe Vittorio De Socio
    Unit of Infectious Diseases Hospital "Santa Maria della Misericordia" Piazzale Menghini,1 – 06129 Perugia (PG), Italy Phone: +390755784319 – Fax: +390755784346, Italy | giuseppedesocio@yahoo.it
  • Gianluigi Fabbriciani
    Rheumatology Unit, IRCCS Humanitas Clinical Institute, Rozzano (Milano),, Italy
  • Marco Massarotti
    Rheumatology Unit, IRCCS Humanitas Clinical Institute, Rozzano (Milano), Italy, Italy
  • Salvatore Messina
    Nuclear Medicine 1, Hospital “Santa Maria della Misericordia”, Perugia, Italy,
  • Enisia Cecchini
    Unit of Infectious Diseases Hospital "Santa Maria della Misericordia" Piazzale Menghini,1 – 06129 Perugia (PG), Italy,
  • Bianca Marasini
    Rheumatology Unit, IRCCS Humanitas Clinical Institute, Rozzano (Milano), University of Milano, Italy,


Tenofovir is widely used as first-line treatment of HIV infection, although its use is sometimes complicated by a reversible proximal renal tubulopathy.

We report the case of a 45-year-old woman with chronic HIV infection and personality disorder, who after 12 months of tenofovir, complained of fatigue, diffuse bone pain and gait disturbances. The elevated level of alkaline phosphatase, hypophosphatemia and inappropriate phosphaturia suggested the diagnosis of hypophosphatemic osteomalacia secondary to proximal renal tubulopathy. A dual-energy x-ray absorptiometry showed a bone mineral density below the expected range for age (lumbar spine Z-score -3.3, femoral neck Z-score -2.1). A whole body 99mTc-methylene diphosphonate bone scan showed multiple areas of increased focal activity in the lumbar and thoracic spine and in sacroiliac and hip joints consistent with pseudo-fractures. Two months after tenofovir discontinuation and administration of vitamin D and phosphate, osteomalacia-related symptoms disappeared. Eleven months later, bone and mineral metabolism data were normal and bone scintigraphy did not show any pathological findings.

This report highlights the importance of considering the diagnosis of osteomalacia in patients treated with tenofovir and emphasizes the need for monitoring alkaline phosphatase, blood and urinary phosphate and creatinine, especially in patients with risk factors for bone disease.


Tenofovir; HIV infection; Hypophosphatemia; Alkaline phosphatase; Pseudofractures.

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Submitted: 2014-06-13 09:33:05
Published: 2012-05-04 00:00:00
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