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Patient Case: Paget’s Disease of Bone

Patient Case: Paget’s Disease of Bone

Discussion

A 62-year-old male presents to a local clinic with persistent deep aching pain in his right hip and lower back for the past year. He describes the pain as worsening at rest and unrelated to physical activity. He also reports occasional headaches and a sensation of fullness in his skull. His family members have noticed a slight bowing of his right leg over the past few months.

On examination, there is mild warmth over the right hip and tibia, along with localized bone tenderness. No joint swelling is noted. Laboratory tests show an isolated elevation in alkaline phosphatase with normal calcium and phosphate levels. X-rays of the pelvis and femur reveal thickened, deformed cortical bone with a "cotton wool" appearance in the skull.

A diagnosis of Paget’s disease of bone is made. The patient is started on bisphosphonates to slow bone turnover and advised on calcium and vitamin D supplementation. Regular follow-up is planned to monitor for complications, including fractures and hearing loss.

Questions
1. What is the most likely diagnosis in this patient?

a) Osteoporosis

b) Paget’s disease of bone

c) Osteoarthritis

d) Multiple myeloma

2. Which of the following laboratory findings is most characteristic of Paget’s disease of bone?

a) Elevated alkaline phosphatase with normal calcium and phosphate levels

b) Low alkaline phosphatase with high calcium

c) Elevated parathyroid hormone (PTH)

d) Markedly low vitamin D levels

3. What is the first-line treatment for Paget's bone disease of bone?

a) Nonsteroidal anti-inflammatory drugs (NSAIDs)

b) Bisphosphonates

c) Corticosteroids

d) Calcitonin

4. Which of the following complications is most commonly associated with untreated Paget’s disease?

a) Increased risk of pathological fractures and hearing loss

b) Severe joint erosion and autoimmune arthritis

c) Rapid progression to bone cancer in all cases

d) Complete resolution without treatment

Reveal answers

Answers

1. b) Paget’s disease of bone

The patient’s localized bone pain, skull changes, elevated alkaline phosphatase, and characteristic "cotton wool" appearance on X-ray strongly suggest Paget’s disease, a disorder of excessive bone remodeling.

2. a) Elevated alkaline phosphatase with normal calcium and phosphate levels

Paget’s disease is characterized by high bone turnover, leading to an isolated increase in alkaline phosphatase. Calcium and phosphate levels typically remain normal unless there are complications.

3. b) Bisphosphonates

Bisphosphonates, such as zoledronic acid, are the mainstay of treatment to reduce excessive bone resorption and prevent complications like fractures and bone deformities.

4. a) Increased risk of pathological fractures and hearing loss

Untreated Paget’s disease can lead to fragile, deformed bones, increasing the risk of fractures. Skull involvement may cause hearing loss due to compression of cranial nerves.