In Paget disease of bone, overactive breakdown and rebuilding in one or a few bones produces bone that is larger but weaker and poorly organized. It usually affects adults over 55, often in the pelvis, skull, spine or legs, and many cases are found by chance.
Key symptoms
- Often no symptoms; found from a high alkaline phosphatase or an X-ray
- Deep, aching bone pain that may persist at rest
- Bowing of a leg or an enlarging skull, with hats no longer fitting
- Hearing loss or headache when the skull is involved
What you find on exam
- Bowed femur or tibia with warmth over the bone
- Enlarged skull or frontal bossing
- Hearing check and cranial nerve exam
- Joint exam for arthritis next to an affected bone
Tests
- Raised alkaline phosphatase with normal calcium and phosphate
- X-ray: thickened cortex, coarse trabeculae and enlarged bone
- Bone scan to find all affected bones
- Calcium and vitamin D levels before treatment
Treatment basics
- Zoledronic acid, a single IV bisphosphonate dose, for active or symptomatic disease
- Make sure calcium and vitamin D are adequate before a bisphosphonate
- Pain control with acetaminophen or NSAIDs
- Orthopedic surgery for fractures, deformity or severe arthritis
Red flags
- Sudden increase in pain or a new mass in an affected bone, which can signal osteosarcoma
- New leg weakness, numbness or bladder changes from spinal compression
- Fracture of a bowed bone after minor trauma
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Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.