A 63-year-old asymptomatic woman is seen in the clinic for investigation of a persistently elevated alkaline phosphatase (ALP) level. The elevated ALP is an isolated finding and the remaining liver enzymes are normal. She reports no abdominal symptoms suggestive of biliary colic or hepatitis.On physical examination, the vital signs are normal, she is not icteric, the heart sounds are normal and the lungs are clear. The abdomen is soft and the liver span is 12 cm in the mid- clavicular line.X-rays of the pelvis show multiple porotic and sclerotic lesions with characteristic whorls of trabeculation. Her excretion of urinary hydroxyproline is also elevated. Which of the following is the most likely diagnosis?
Correct Answer: Paget disease of bone
Description: The elevated ALP and hydroxyproline are diagnostic for Paget disease. The bony lesions are osteoblastic, and the sacrum and pelvis are most frequently involved, followed closely by the tibia and femur. Hypercalcemia is not usually a feature of Paget, though can occur as a complication of immobilization. The etiology is unknown. Symptoms may be absent or severe (pain, deformity). In metastatic cancers of most types the lesion are lytic, and the other metabolic abnormalities listed do not have an elevation in hydroxyproline.
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