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+A 47-year-old female patient presented progressively worsening pain in the chest wall, back, and bilateral lower extremities as well as muscle weakness.
+She did not have a family history of bone disease or fractures.
+Physical examination was unremarkable excluding bone and muscular abnormalities.
+Bone scintigraphy using technetium-99m methylenediphosphate showed increased uptake in the shoulder, multiple ribs, thoracic and lumbar spines, bilateral sacroiliac joints, left ilium, and left foot (Fig.1).
+Plain radiographs revealed osteoporosis change of thoracic and lumbar spine as well as compression change of several spines, consistent with findings of magnetic resonance imaging and computed tomography (CT) (Fig.1).
+Decreased bone mass was presented in the lumbar spine (T-score: −3.4), femoral neck (T-score: −3.1), and hip (T-score: −3.5).
+Main laboratory data are shown in Table ​1.
+She demonstrated hypophosphatemia, hypokalemia, hypouricemia, elevated level of ALP, C-telopeptides and chloride, and decreased carbon dioxide combining power.
+The urinalysis revealed a high pH value, increased level of potassium, and decreased level of specific gravity, chlorine, and phosphate.
+Persistent glycosuria and proteinuria were repeatedly found, despite normal HbA1c and plasma glucose level.
+Other laboratory test results including thyroid function test, serum parathyroid hormone, 25-hydroxyvitamin D, and protein electrophoresis were within normal range.
+In addition, all of serum tumor markers were negative.
+Due to limited technique, we cannot determine the level of serum fibroblast growth factor 23.
+With the clinical diagnosis of HO, fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) and technetium-99m octreotide (99mTc-OCT) scintigraphy were performed to confirm whether the occult causative tumor exist.
+However, the results of these 2 tests were negative except that mild uptake in the seventh rib was found on PET/CT, which identified no evidence of a neoplastic lesion potentially responsible for HO (Fig.2).
+The immunological examination showed elevated level of serum IgG, IgM, and IgA, as well as positive antinuclear antibody, anti-SSA antibody, and rheumatic factor.
+Subsequently, Schirmer test was abnormal and lip biopsy supported the diagnosis of SS (Fig.3).
+Eventually, this patient was diagnosed with HO secondary to SS, and she was then treated with alkalinization (citrate 4 g/day and potassium citrate 3 g/day for 2 weeks), steroids (prednisone 20 mg/day for 1 month, 10 mg/day for 4 months), neutral phosphate (1.0 g/day for 5 months), calcium supplements (600 mg/day for 5 months), and together with activated vitamin D (0.5 g/day for 5 months).
+So far, she recovered uneventfully with relieved pain and increased serum phosphorus level.
+This case report was approved by the ethics committee of West China Hospital of Sichuan University, Chengdu, China, and the written informed consent was obtained.