Osteomalacia mimicking skeletal metastasis induced by antacid and sucralfate: An interesting image on bone scintigraphy

Phosphate absorption can be blocked by over-the-counter antacids, such as calcium- magnesium-, and aluminum-containing products. Although it is rare to see hypophosphatemia induced by aluminum-containing antacids, the combination treatment using two kinds of aluminum-containing agents may significantly increase the risk of hypophosphatemia in clinical settings. We present a case of hepatocellular carcinoma, showing multiple hot spots while being investigated for metastatic cancer in a routine bone scan. Initial laboratory studies showed hypophosphatemia. Long-term treatment for upper gastrointestinal bleeding with antacids and sucralfate was remarkable in the patient’s past history. Compared with corresponding radiographic findings, multiple areas of increased uptake on the bone scan are consistent with osteomalacia and microfractures. This case demonstrates that antacid and sucralfate-induced osteomalacia can mimic bony metastasis in a hepatocellular carcinoma patient on bone scintigraphy. Additional imaging modality, laboratory surveillance or follow-up bone scintigraphy may be recommended for accurate diagnosis or an appropriate treatment plan for the patient.