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The case is presented of a previously healthy 45\u2010year\u2010old man who developed fragility fractures at multiple sites (initially metatarsals, eventually ribs, hips, spine, scapula, and sacrum) resulting in rapid functional deterioration, weakness, and the inability to bear weight and ambulate without a walker. Workup for secondary causes of bone loss was negative except for mild hypogonadotropic hypogonadism with normal pituitary MRI and hypophosphatemia that persisted despite aggressive supplementation. Testosterone was initiated but discontinued 6\u2009months later because of deep vein thrombosis and pulmonary embolism, likely provoked by his new sedentary state, in addition to smoking history and possibly testosterone usage. Serum FGF23 was nonelevated at 138\u2009mRU\/mL (44\u2013215). A genetic panel for OI variants was negative for a causal mutation. At the age of 48, 3\u2009years after his initial fracture, he was referred to our academic endocrine clinic. We ruled out additional mutations that lead to hypophosphatemic rickets, including phosphate\u2010regulating endopeptidase homolog, X\u2010linked. PET\/CT looking for a potential TIO locus revealed uptake in the left suprapatellar recess. Biopsy was consistent with a phosphaturic mesenchymal tumor. FGF23 was repeated for a preoperative baseline and now found to be elevated at 289\u2009mRU\/mL. In retrospect, it is likely that the initial level was inappropriately elevated for the degree of hypophosphatemia. After resection, he experienced marked improvement in physical function, decreased pain, and resolution of renal phosphate wasting. The principals of establishing a robust clinical diagnosis of TIO should be emphasized, excluding other entities and avoiding pitfalls in the interpretation of laboratory testing. \u00a9 2020 The Authors. <jats:italic>JBMR Plus<\/jats:italic> published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.<\/jats:p>","DOI":"10.1002\/jbm4.10438","type":"journal-article","created":{"date-parts":[[2020,11,25]],"date-time":"2020-11-25T03:46:50Z","timestamp":1606276010000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["A Normal <scp>FGF23<\/scp> Does Not Preclude Tumor\u2010Induced Osteomalacia"],"prefix":"10.1093","volume":"5","author":[{"given":"Neeharika","family":"Nandam","sequence":"first","affiliation":[{"name":"Department of Medicine, Division of Endocrinology and Metabolism University of North Carolina at Chapel Hill  Chapel Hill NC USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sadia","family":"Ejaz","sequence":"additional","affiliation":[{"name":"Department of Medicine, Division of Endocrinology and Metabolism University of North Carolina at Chapel Hill  Chapel Hill NC USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William","family":"Ahrens","sequence":"additional","affiliation":[{"name":"Department of Pathology Carolinas Medical Center  Charlotte NC USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9790-8645","authenticated-orcid":false,"given":"Maya","family":"Styner","sequence":"additional","affiliation":[{"name":"Department of Medicine, Division of Endocrinology and Metabolism University of North Carolina at Chapel Hill  Chapel Hill NC USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2020,12,23]]},"reference":[{"key":"e_1_2_8_2_1","first-page":"554","article-title":"Rickets following bone tumor","volume":"14","author":"Prader A","year":"1959","journal-title":"Helv Paediatr Acta."},{"issue":"3","key":"e_1_2_8_3_1","first-page":"209","volume":"11","author":"Prader A","year":"1956","journal-title":"Helv Paediatr Acta"},{"issue":"2","key":"e_1_2_8_4_1","first-page":"91","article-title":"Die famili\u00e4re vitamin D\u2010resistente rachitis [Familial vitamin D\u2010resistant rickets]","volume":"186","author":"Tobler R","year":"1956","journal-title":"Helv Paediatr Acta."},{"key":"e_1_2_8_5_1","doi-asserted-by":"publisher","DOI":"10.1073\/pnas.101545198"},{"key":"e_1_2_8_6_1","doi-asserted-by":"publisher","DOI":"10.1073\/pnas.111154898"},{"key":"e_1_2_8_7_1","unstructured":"ErbenRG AndrukhovaO.FGF23\u2010Klotho signaling axis in the kidney [Internet]. 2016 [cited 2020 May 4]. 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