1. MedPix Medical Image Database COW - Case of the Week Case Contributor: Paul J. Shogan Affiliation: National Capital Consortium

2. MedPix No: 11965 - History Pt Demographics: Age = 60 y.o. Gender = man 60 yo male for evaluation. Downloaded by (-1)

3. MedPix No: 11965 - EXAM & LABS

4. Pagets Disease of Bone Scout image of the lower extremities reveals bowing of the left femur, with an osseous abnormality involving the distal femur. Downloaded by (-1)

5. Pagets Disease of Bone AP radiograph of the left femur reveals the blade of grass appearance of osteoclastic activity in the mid-shaft cortex with sharp borders, advancing along the shaft of the femur. Additionally, bone remodeling with thickening of the cortex, and a coarse trabecular pattern in the medullary portion of the femur is noted. There is also a increase in bone density, with diffuse sclerotic change, enlargement and widening of the epiphysis. Bowing is evident. Involvement of the proximal medial tibia is also noted. - - Downloaded by (-1)

6. Pagets Disease of Bone Lateral radiograph of the left femur reveals the blade of grass appearance of osteoclastic activity in the mid-shaft cortex with sharp borders, advancing along the shaft of the femur. Additionally, bone remodeling with thickening of the cortex, and a coarse trabecular pattern in the medullary portion of the femur is noted. There is also a increase in bone density, with diffuse sclerotic change, enlargement and widening of the epiphysis. Involvement of the proximal medial tibia is also noted. - - Downloaded by (-1)

7. Pagets Disease of Bone Frog leg radiograph of the left femur, reveals the blade of grass appearance of osteoclastic activity advancing along the shaft of the femur. - - Downloaded by (-1)

8. FINDINGS Scout image reveals bowing of the left femur, with an osseous abnormality involving the distal femur.AP and lateral radiograph of the left femur reveals a blade of grass appearance of osteoclastic activity in the mid-shaft cortex with sharp borders, advancing along the shaft of the femur. Additionally, bone remodeling with thickening of the cortex, and a coarse trabecular pattern in the medullary portion of the femur is noted. There is also a increase in bone density, with diffuse sclerotic change, enlargement and widening of the epiphysis. Bowing is evident. Frog leg radiograph of the left femur, reveals the blade of grass appearance of osteoclastic activity advancing along the shaft of the femur.

9. DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? Lymphoma - Metastatic cancer - Familial idiopathic hyperphosphatasia (Juvenile Paget disease) where the articular ends of the bone may not be affected. - Paget Disease

10. Diagnosis: Paget Disease of Bone Dx Confirmed by: Imaging findings are characteristic.

11. DISCUSSION If laboratory markers had been drawn, one would expect increased levels of serum alkaline phosphatase with osteoblastic activity, and high urinary levels of hydroxyproline with osteoclastic activity. - - Complications of Paget*s disease include deformity of the long bones, warmth in the involved extremity, periosteal tenderness, bone pain, fractures, secondary osteoarthritis, neural compression, and sarcomatous degeneration. - - Greenspan, Adam. Orthopedic Radiology: A Practical Approach. 2nd Edition. Lippincott- Raven Publishers Philadelphia, PA, 1997. - - -