Review Question - QID 102581

This patient is presenting with persistent left hip pain (even prior to the accident), heterogeneous density of the bone noted on CT, and an elevated alkaline phosphatase with a normal calcium/PTH suggesting a diagnosis of Paget disease of the bone.

Paget disease of the bone is a metabolic disorder of abnormal bone remodeling. In Paget disease of the bone increased osteoclastic bone resorption and increased osteoblastic bone formation can cause skull deformities and aching bone/joint pain. Patients with Paget disease of the bone will demonstrate a normal calcium and an elevated alkaline phosphatase (from the pathologic bone remodeling). Radiography may demonstrate remodeled cortices and coarsened trabeculae giving the bone a blastic appearance. Other presenting symptoms in Paget disease of the bone include hearing loss (from CN VIII compression), headache, spinal stenosis, radiculopathies, and fractures. The medical treatment of this condition is a bisphosphonate which inhibits the pathologic remodeling.

Figure A demonstrates a CT scan of an individual with Paget bone disease. Note the thicker trabeculae and cortex in addition to the heterogeneous density of the bone.

Incorrect Answers:
Answer 1: Multiple myeloma is a malignancy of monoclonal plasma cells which produce large amounts of Ig. The characteristic finding on radiograph for this pathology is punched-out lytic bone lesions. Patients will often be elderly and present with a pathologic fracture and bony tenderness.

Answer 2: Osteoarthritis presents with joint pain and a narrowed joint space on radiography typically in a weight bearing joint with pain worse with exertion and relieved with rest.

Answer 3: Osteogenic sarcoma is a malignant neoplasm of the bone that often presents with the classic finding of a radiograph depicting Codman triangle. This triangle is essentially a subperiosteal lesion formed when the periosteum is raised due to the tumor. This is a complication of Paget disease of the bone but is not present on this patient's radiograph.

Answer 5: Rheumatoid arthritis typically presents in a woman with symmetric joint pain that is worse in the morning that improves with exertion/by the end of the day. Chronic disease can lead to permanent joint damage and deformities.

Bullet Summary:
Paget disease of the bone presents with bone pain, an elevated alkaline phosphatase, and sclerotic/lytic lesions on radiography.