A 68-year-old man comes to the office with a deep headache throughout the day for the past 2 months. He works as a construction foreman and says his hard hat has felt unusually tight during that time, which he believes may be contributing to his symptoms. The patient has no associated muscle weakness, sensory changes, or eye symptoms. Laboratory studies show an elevated serum alkaline phosphatase level of 656 U/L. His other liver function tests are within normal limits, and serum calcium and phosphorus levels are normal. Erythrocyte sedimentation rate and serum prostate-specific antigen are also normal. CT scan of the head reveals no brain lesions, but the skull has thickened cortices with mixed lytic and osteoblastic lesions. Nuclear bone scan reveals increased uptake in the skull and tibia. In addition to optimization of vitamin D and calcium intake, which of the following is the most appropriate next step in management of this patient?

Question

A 68-year-old man comes to the office with a deep headache throughout the day for the past 2 months.  He works as a construction foreman and says his hard hat has felt unusually tight during that time, which he believes may be contributing to his symptoms.  The patient has no associated muscle weakness, sensory changes, or eye symptoms.  Laboratory studies show an elevated serum alkaline phosphatase level of 656 U/L.  His other liver function tests are within normal limits, and serum calcium and phosphorus levels are normal.  Erythrocyte sedimentation rate and serum prostate-specific antigen are also normal.  CT scan of the head reveals no brain lesions, but the skull has thickened cortices with mixed lytic and osteoblastic lesions.  Nuclear bone scan reveals increased uptake in the skull and tibia.  In addition to optimization of vitamin D and calcium intake, which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d513_1ff1_bc81_a5b4def0edf2_MD0003_00 This patient has Paget disease of bone characterized by an elevated serum alkaline phosphatase level, mixed osteolytic and sclerotic bone lesions, and focal uptake of radiotracer on bone scan. Paget disease is due to disordered osteoclastic bone resorption and can lead 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, headaches, cranial nerve dysfunction, and hearing loss. Asymptomatic patients with minimal disease activity (eg, incidental discovery of mildly increased alkaline phosphatase level) may be observed without being treated. However, symptomatic patients and those with involvement of high-risk skeletal structures (eg, skull, weight-bearing long bones) should be treated to reduce pain and decrease the risk of complications. Bisphosphonates (eg, alendronate, zoledronic acid) inhibit osteoclasts and suppress bone turnover and are the preferred therapy. (Choice B) Calcitonin also inhibits osteoclastic bone resorption and reduces disease activity in Paget disease but has a weaker effect than bisphosphonates. (Choice C) Infliximab is an antitumor necrosis factor agent used in the treatment of rheumatoid arthritis, psoriasis, ankylosing spondylitis, and Crohn disease. (Choices D and E) Methotrexate is used for treating inflammatory conditions (eg, rheumatoid arthritis, psoriasis) and certain malignancies. Prednisone is also effective for autoimmune or inflammatory conditions. However, neither of these is effective for Paget disease. (Choice F) Testosterone deficiency causes fatigue, erectile dysfunction, and gynecomastia and can lead to osteoporosis. However, it does not cause osteolytic lesions. Educational objective: Patients with symptomatic Paget disease of bone and those with involvement of high-risk skeletal structures (eg, skull, weight-bearing long bones) should be treated to reduce pain and decrease the risk of complications. Bisphosphonates inhibit osteoclasts and suppress bone turnover and are the preferred therapy. References: Clinical practice: Paget's disease of bone. (http://www.ncbi.nlm.nih.gov/pubmed/23406029)

A 68-Year-Old Man Comes to the Office with a Deep