A 65-year-old man comes to the clinic due to left thigh pain. The pain has been present for several months with constant, moderate severity. The patient has no recent history of trauma, and there is no associated weight change or loss of appetite. Medical history is significant only for high blood pressure. He does not use tobacco, alcohol, or illicit drugs. Temperature is 37.2 C (98.9 F), blood pressure is 138/88 mm Hg, pulse is 80/min, and respirations are 12/min. On examination, the lower back and hips have no apparent deformity, warmth, or erythema. There is normal, pain-free range of motion at the hip. His gait is mildly antalgic. Lower-extremity reflexes, motor strength, and sensation are normal, and the patient has full pedal pulses. Laboratory results are as follows: X-ray reveals cortical thickening in the left femur. Bone scintigraphy shows increased radiotracer uptake in several spots, including the left femur. This patient is at highest risk of developing which of the following complications?

Question

A 65-year-old man comes to the clinic due to left thigh pain.  The pain has been present for several months with constant, moderate severity.  The patient has no recent history of trauma, and there is no associated weight change or loss of appetite.  Medical history is significant only for high blood pressure.  He does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.2 C (98.9 F), blood pressure is 138/88 mm Hg, pulse is 80/min, and respirations are 12/min.  On examination, the lower back and hips have no apparent deformity, warmth, or erythema.  There is normal, pain-free range of motion at the hip.  His gait is mildly antalgic.  Lower-extremity reflexes, motor strength, and sensation are normal, and the patient has full pedal pulses.  Laboratory results are as follows:  X-ray reveals cortical thickening in the left femur.  Bone scintigraphy shows increased radiotracer uptake in several spots, including the left femur.  This patient is at highest risk of developing which of the following complications?

Quizplus · Accepted Answer

11ec25c8_d512_358e_bc81_738c301e1ade_MD0003_00 This patient with focal bone pain and an elevated alkaline phosphatase level has typical features of Paget disease of bone, a common disorder in older adults. Paget disease is characterized by abnormal osteoclast activity leading to increased bone turnover and disordered bone remodeling. Typical findings on imaging include cortical thickening and osteolytic or mixed lytic/sclerotic lesions on x-ray as well as focally increased radiotracer uptake on bone scan. disordered bone remodeling Patients with Paget disease can develop symptoms due to focal enlargement, weakness, or fracture of bone. Bowing of long bones, bone pain, and arthritis in adjacent joints are common. Involvement of cranial bones may cause frontal bossing, increased hat size, headaches, and cranial nerve palsies. Hearing loss may occur due to enlargement of the temporal bone and encroachment on the cochlea. (Choice A) Multiple myeloma can cause bone pain and focal lytic lesions. Potential complications include acute and chronic kidney injury. However, patients would typically have hypercalcemia and systemic symptoms (eg, weight loss, fatigue). (Choice C) Asymptomatic, isolated elevations in alkaline phosphatase can occur in primary biliary cholangitis (formerly primary biliary cirrhosis), which can occasionally lead to cirrhosis. Bony abnormalities would not be seen. (Choice D) Pulmonary hemorrhage can be seen in autoimmune disorders (eg, Goodpasture syndrome), coagulation disorders, and valvular heart disease and following bone marrow transplant. Paget disease does not lead to pulmonary complications. (Choice E) Risk factors for renal cell carcinoma include smoking, hypertension, obesity, and a variety of inherited disorders (eg, von Hippel-Lindau syndrome). The risk for renal cell carcinoma is not increased in Paget disease. (Choice F) Risk factors for subarachnoid hemorrhage include hypertension, smoking, fibromuscular dysplasia, and certain inherited disorders (eg, Ehlers-Danlos syndrome, polycystic kidney disease). Educational objective: Paget disease can cause focal enlargement, weakness, or fracture of bone. Bowing of long bones, bone pain, and arthritis in adjacent joints are common. Involvement of cranial bones may cause frontal bossing, headaches, cranial nerve dysfunction, and hearing loss.

A 65-Year-Old Man Comes to the Clinic Due to Left