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GFLIP
01-28-2007, 02:47 PM
A 57 yo male comes into you office complaining of bone pain. After a detailed history, the patient tells you that his hat doesn't fit anymore. You decide to get some labs which show increase in alkaline phosphatase. You know that the patients condition causes abnormal and excessive bone remodeling. What drug would would be best to slow pregression?

a. SERM
b. Vitamin D
c. calcium
d. bisphosphanates

MDiva
01-29-2007, 09:30 AM
Sounds like Paget's disease. Bisphosphonates are the DOC.

GFLIP
02-20-2007, 11:09 PM
this is a nice imp pic for paget's...

Dr. X
02-21-2007, 11:01 AM
his hat doesn't fit anymore

ah, i thought this was kinda weird. I wonder to what extent this actually happens to people with pagets.

just so this post is not totally useless: the pain would be stabbing pain. the actual term of disease: "osteitis deformans" and remember that calcium and phosphorus would remain normal. hypertension may occur leading to heart failure.

MDiva
02-22-2007, 08:10 AM
I always thought the "hat doesn't fit anymore" was a classic give away for Paget's diz of bone, as I have seen it over and over in practice questions, even on my exams in school. Therefore, it's probably not likely to show up like that on the step 1. So the pain, elevated alk phos, and a bone biopsy pic like the one GFLIP provided are good enough for making the Dx. What is the DDX for elevated alk phos and pain?

GFLIP
03-02-2007, 08:35 PM
you see elevated alk phos and bone pain in osteomalacia... was this what you were thinking?

IMG SURVIVOR
03-02-2007, 09:06 PM
I think Im a little outdated here :0), I always taught big head= acromegaly

Also remember about the brown color in the bone in patients with paget disease.

WHo know why is brown?
and what hormone might be elevated?
What diseases you see elevated Phosphate alkaline

IMG SURVIVOR
03-02-2007, 09:07 PM
hey guys/girls what is SERM?

Dr. X
03-05-2007, 10:05 AM
some reasons for increased Alk. phosphate is paget's, hyperparathyroidism and vit. D toxicity. differentiate pagets from hyperparathyroidism by checking the ca+. normal and increased, respectively.

since osteomalacia(adults), and rickets(children) are caused by vit. D deficiency, i dont see how alk. phosphate would increase. im not sure if it decreases or normal so gonna stay from that. if it does increase for some reason, someone could explain so we all learn.

acromegaly - ya, GH tends to make alot of things bigger. so you would also see upper and lower extremities being bigger as well. altogether known as "gigantism". so if its only big head with bony deformities and multiple fractures, its safer to lean towards paget.

brown color could be due to the cystic spaces being filled with osteoclast with fibrous stroma and blood. correct me if im wrong. also remember, this is not a topic of brown fat.

and serm = selective estrogen receptor modulator.

its a receptor on estrogen that has:
agonistic effects ---> liver and bone.
antagonistic effects --> breast and uterus.

drugs like raloxifene (for atherosclerosis in women), binds to SERM producing agonistic effects. (remember how estrogen helps women from heart failures). the problem is that during a long course of drug therapy, they are at risk for breast cancer and endometrial cancer.

IMG SURVIVOR
03-05-2007, 11:10 AM
vERY GOOD Dr X



How can you diferiantiate Alkaline phosphate from bone and from liver?

MDiva
03-06-2007, 10:16 AM
Thanks GFLIP and Dr. X, for your responses for the DDx of elevated alk phos and bone pain. Another one would be malignancy.

To tell the difference between liver and bone, would you look at the LFTs? If they were normal, then look at the bones?

GFLIP
07-16-2007, 06:55 PM
How can you diferiantiate Alkaline phosphate from bone and from liver?
GGT (gamma-glutamyltransferase) test will confirm hepatic origin of elevated alk. phosphatase

GFLIP
07-16-2007, 06:57 PM
Abnormal alkaline phosphatase elevation can be seen in hepatobililary disease, bone disease, pregnancy, hyperthyroidism, lymphoma, hypernephroma, cardiac failure

student-2
07-20-2007, 04:30 AM
Pagets- overactive (independantly) osteoblasts and osteoclasts. The osteoblasts can account for the higher alk. phos. PTH levels are normal- the defect is in the cells.
The whole song and dance about the hat is a classic testing clue- rarely does a patient come up and discuss hat sizes unless asked of course. I actually have a good picture of a man with paget and his head is huge. I will scan it some time when I have more time.

BTW- acromegaly is also classicaly clued for by a non fitting hat and old photos.







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