Primary intestinal lymphangiectasis (PIL), also known as Waldmann's disease, is 
a rare protein-losing enteropathy characterized by abnormal enlargement of the 
lymphatic ducts in the bowel wall. The symptoms usually start in early infancy. 
We report a case of osteomalacia in a 63-year-old patient with delayed-onset of 
PIL, for which she was on dietary treatment. She presented with a 3-year history 
of mechanical pain in the back and pelvis. Mild ascites and edema with 
functional impairment of the lower limbs were noted. The neurological evaluation 
was normal. Blood tests showed hypocalcemia, hypophosphatemia, alkaline 
phosphatase elevation, and evidence of intestinal malabsorption. Radiographs of 
the pelvis disclosed a fracture, Looser's zones in the iliopubic rami and left 
femoral neck, and a washed-out appearance of the vertebras. Dual-energy X-ray 
absorptiometry showed bone loss with T-score values of -1.2SD at the lumbar 
spine and -2.5SD at the femoral necks. A diagnosis of osteomalacia related to 
vitamin D deficiency was given. Serum 25-OH-vitamin D was 18.2ng/ml (normal, 
20-40ng/ml) and serum parathyroid hormone was 620pg/ml (normal, 15-65pg/ml), 
suggesting secondary hyperparathyroidism. Intramuscular vitamin D was given, 
together with oral calcium and an adequate diet. At follow-up 8 months later, 
small improvements were noted in the symptoms and absorptiometry findings.