Paget's disease diagnosed on bone scintigraphy: Case report and literature review
A 46-year-old man, driver by occupation, presented with a history of sudden onset pain abdomen, which was colicky in nature and localized to the right lumbar region. There was no history of dysurea, hematuria, fever, loose stools, or vomiting. He also had a history of multiple joint pains for the last 4 months, aggravated for the past 1 week. He also complained of excessive worries, tension, and having sleep disturbance. There was no history of fever, weight loss, skin rash, loss of appetite, or backache. There was no past history of diabetes, hypertension, tuberculosis, polyarthritis, or any other significant illness. His family history was not contributory. Investigations revealed normal hemogram and urine examination. His blood urea, creatinine, LFT, electrolytes, and sugar levels were normal. Abdominal ultrasound revealed bilateral renal calculi with gross pelvicalyceal dilatation of right kidney and right hydroureter. Renal pyelogram showed non-functioning right kidney with multiple left-sided renal calculi. Tc99m diethylene triamine pentaacetic acid (DTPA) renogram revealed normal functioning and draining left kidney with a GFR of 55 ml/min and poorly functioning right kidney with a GFR of 10 ml/min. The patient underwent ureteroscopy with intra-corporeal lithotripsy of right kidney and bilateral DJ stenting. In addition, he underwent multiple sittings of extracorporeal shock wave lithotripsy. He had normal ESR, negative CRP, negative rheumatoid factor, serum ionised calcium 4.4 mg/dL, and serum alkaline phosphatase 86 IU/ml. Whole-body bone scan done revealed extremely hot focus involving the right humerus (head and proximal shaft) and left hemipelvis-features, suggestive of Paget's disease []. X-rays of right humerus and pelvis did not reveal any abnormality []. Magnetic resonance imaging (MRI) showed thickened cortex with altered signal intensity involving the right humerus head and proximal shaft and left iliac bone, commensurate with the bone scan findings [Figures and ]. A bone biopsy from left iliac crest was done, which showed irregular bony trabeculae lined by plump osteoblasts, with multinucleate osteoclasts and increase in cement lines []. Serum calcium was 9 mg/dL and PTH level was 12 pg/ml, both normal. Hence, a diagnosis of Paget's disease was made and the patient was started on biphosphonate therapy. He is under follow-up and has shown marked improvement in symptoms.