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OBJECTIVES Hyperphosphatemic familial tumoral calcinosis/hyperostosis-hyperphosphatemia syndrome (HFTC/HHS) is a rare disorder caused by deficiency or resistance of fibroblast growth factor 23 (FGF23). Here we reported a Chinese family with HFTC/HHS, aiming at clarifying the clinical features, bone microarchitectures and molecular mechanisms of the disease. METHODS Clinical manifestations, laboratory examinations and genetic analyses were collected from two HFTC patients. Bone microarchitectures were detected by HR-pQCT. In vitro expression and glycosylation of mutant and wild-type FGF23 proteins were analyzed by western blotting and wheat germ agglutinin affinity chromatography. Subcellular localizations of FGF23 proteins were detected by immunocytochemistry. RESULTS The two brothers carried previously unreported c.413 T > G, p.Leu138Arg and c.491 T > A, p.Ile164Asn compound heterozygous variants in the FGF23 gene, which was "likely pathogenic" according to American College of Medical Genetics (ACMG) Standards and Guidelines. Both patients had severe hyperphosphatemia and significantly elevated C-terminal FGF23. With HHS, patient 1 presented with lower extremity pain and widespread cardiovascular calcification. HR-pQCT of his distal radius and tibia revealed decreased volume BMD and cortical thickness, which were inconsistent with hyperostosis manifestations in X-ray. He received etidronate treatment, which improved his BMD and the ectopic calcification. His brother exhibited less bone involvement but had experienced recurrent painful calcified mass from a young age and undergone several resections. In vitro experiments showed that the mutant FGF23 proteins had defective O-glycosylation and impaired secretion. However, no difference in subcellular localization was found between the wild-type and mutant FGF23 proteins. CONCLUSION We have presented a Chinese HFTC/HHS family with novel FGF23 c.413 T > G, p.Leu138Arg and c.491 T > A, p.Ile164Asn variants. We clarified the bone microarchitectures of HFTC/HHS patients by HR-pQCT, and expanded the genotype-phenotype spectrum of the disease. In vivo studies suggested that O-glycosylation of FGF23 plays an important role in the pathogenesis of HFTC/HHS, providing further understanding of the disease mechanism.