Osteoporosis International

, Volume 30, Issue 2, pp 519–523 | Cite as

Severe hypophosphatemia induced by denosumab in a patient with osteomalacia and tenofovir disoproxil fumarate-related acquired Fanconi syndrome

  • T.-L. Chung
  • N.-C. Chen
  • C.-L. ChenEmail author
Case Report


Denosumab, a novel agent that inhibits osteoclasts, reduces the risk of fracture in patients with osteoporosis. However, worsening of hypophosphatemia and other symptoms may be induced by denosumab in patients with pre-existing hypophosphatemic osteomalacia. A 58-year-old man with hepatitis B presented with diffuse bone pain and muscle weakness. Denosumab was prescribed by the orthopedist according to documented low bone mass and spine compression fracture. After administering denosumab, the patient’s bone pain worsened, and he later developed a right tibia stress fracture. His condition was diagnosed as adult-onset hypophosphatemic osteomalacia complicated by multiple bone fractures, which resulted from Fanconi syndrome with proximal tubulopathy due to tenofovir disoproxil fumarate (TDF) treatment for his hepatitis B. Denosumab use leads to aggressive hypophosphatemic osteomalacia and the complication of stress fractures, because of its effects on bone resorption. Physicians should be aware that in patients with chronic hepatitis B monoinfection who are administered TDF therapy, bone pain or fracture is possible but preventable by timely monitoring of serum phosphate levels. Denosumab should not be used in patients with untreated osteomalacia or vitamin D deficiency, as it may lead not only to hypocalcemia but also to hypophosphatemia in these patients.


Denosumab Fanconi syndrome Hypophosphatemia Osteomalacia Tenofovir 


Author contributions

Study concept and design: Chien-Liang Chen

Acquisition, analysis, and interpretation of data: Chien-Liang Chen and Nai-Ching Chen

Drafting of the manuscript: Tung-Ling Chung, Nai-Ching Chen, and Chien-Liang Chen

Study supervision: Chien-Liang Chen

Compliance with ethical standards

Informed consent

Informed consent was obtained from the participant included in this study.

Conflicts of interest



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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2018

Authors and Affiliations

  1. 1.Division of NephrologyKaohsiung Veterans General HospitalKaohsiungTaiwan
  2. 2.National Yang-Ming University, School of MedicineTaipeiTaiwan
  3. 3.Department of NeurologyKaohsiung Chang Gung Memorial HospitalKaohsiungTaiwan

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