A 65-year-old man comes to the physician for evaluation of a recent x-ray abnormality. Three months ago, he experienced a mild episode of diverticulitis. An abdominal film at that time revealed an abnormality in the pelvis. His diverticular disease has abated and he presents for follow-up. The patient occasionally has some mild aching pain in his left hip and groin area that he attributes to arthritis. He has chronic low back pain that is worse on arising in the morning and improves after ambulation.
The patient has had no fever, chills, or weight loss. He gets up to urinate about three times a night and says that his urine stream isn't what it used to be. He has intermittent gastroesophageal reflux and hypertension. His current medications include lisinopril, lansoprazole, ibuprofen, baby aspirin, and a multivitamin.
The patient appears healthy on examination. His temperature is 36.9 C (98.5 F) , blood pressure is 138/88 mm Hg, pulse is 72/min, and respirations are 14/min. BMI is 29 kg/m². His general examination is within normal limits. Digital rectal examination shows normal sphincter tone and a mildly enlarged soft prostate. There is good range of motion of his hips. There is limited range of motion of his back. He has no motor or sensory deficits of his lower extremities, and reflexes are 2+ and symmetrical.
Laboratory results are as follows:

A review of the x-rays reveals thickening of the femoral neck and diffuse sclerosis of bone that is most prominent in the left hemi-pelvis.
Which of the following would be the most appropriate next step?

Question

A 65-year-old man comes to the physician for evaluation of a recent x-ray abnormality. Three months ago, he experienced a mild episode of diverticulitis. An abdominal film at that time revealed an abnormality in the pelvis. His diverticular disease has abated and he presents for follow-up. The patient occasionally has some mild aching pain in his left hip and groin area that he attributes to arthritis. He has chronic low back pain that is worse on arising in the morning and improves after ambulation.
The patient has had no fever, chills, or weight loss. He gets up to urinate about three times a night and says that his urine stream isn't what it used to be. He has intermittent gastroesophageal reflux and hypertension. His current medications include lisinopril, lansoprazole, ibuprofen, baby aspirin, and a multivitamin.
The patient appears healthy on examination. His temperature is 36.9 C (98.5 F) , blood pressure is 138/88 mm Hg, pulse is 72/min, and respirations are 14/min. BMI is 29 kg/m². His general examination is within normal limits. Digital rectal examination shows normal sphincter tone and a mildly enlarged soft prostate. There is good range of motion of his hips. There is limited range of motion of his back. He has no motor or sensory deficits of his lower extremities, and reflexes are 2+ and symmetrical.
Laboratory results are as follows:

A review of the x-rays reveals thickening of the femoral neck and diffuse sclerosis of bone that is most prominent in the left hemi-pelvis.
Which of the following would be the most appropriate next step?

Quizplus · Accepted Answer

11ec193a_9931_ad99_853d_f156f28d81b7_MD0002_00 This patient's presentation suggests Paget disease. The primary defect is abnormal osteoclasts causing focal areas of accelerated bone resorption. This is followed by increased osteoblast activity, resulting in formation of structurally weaker bone with areas of sclerosis. Commonly affected sites include the skull, thoracic and/or lumbar spine, pelvis, and proximal femurs. Asymptomatic patients are usually diagnosed by routine imaging obtained for another reason or elevated alkaline phosphatase. Depending on the involved site, symptomatic patients may present with persistent and constant bone pain made worse with weight bearing. skull pelvis Laboratory findings usually show an elevated serum and bone alkaline phosphatase. Additional bone turnover markers include procollagen type I N-terminal propeptide (PINP), serum C-telopeptide (CTx), urinary N-telopeptide (NTx), and urinary hydroxyproline. However, bone markers may not be elevated in active disease and are not routinely measured for diagnosis or monitoring (Choice C). Plain radiographs obtained during the early stages of disease show lytic lesions; eventually with osteoblastic response mixed lytic/sclerotic lesions are seen. Elevated alkaline phosphatase levels with the classic radiographic findings (as in this patient) are diagnostic for Paget disease. Once the disease is diagnosed, a bone scan should be obtained in all patients to determine the extent and distribution of bony lesions as the sites involved rarely change over time. In asymptomatic patients, treatment with bisphosphonates is indicated if the bone scan shows active disease at sites where complications could occur (eg, skull, spine, weight-bearing bones). (Choice A) Bone biopsy is usually not needed to confirm or monitor Paget disease in patients with the typical findings as seen in this patient. (Choice D) Parathyroid hormone and vitamin D2 levels would indicate hyperparathyroidism or vitamin D deficiency. However, this patient's calcium is normal and neither condition usually causes the x-ray findings he exhibits. (Choice E) The radiographic features of osteoblastic metastatic prostate cancer can be similar to the typical findings of Paget disease. However, this patient's normal digital rectal examination and prostate-specific antigen level make this less likely. Educational objective: Paget disease of bone can be asymptomatic or present with bone pain. Diagnosis is confirmed by radiographic abnormalities and elevated bone alkaline phosphatase. Bone scan can delineate the extent of disease and guide treatment. Bisphosphonates are the preferred treatment. __________ References: Paget's disease of bone: an update. (http://www.ncbi.nlm.nih.gov/pubmed/21986510) Paget's disease of bone. (http://www.ncbi.nlm.nih.gov/pubmed/22024254)

A 65-Year-Old Man Comes to the Physician for Evaluation of a Recent