Unusual presentation of Paget's disease of bone: BMJ case re
A 60-year-old man presented with sudden onset of ptosis of the right eye. There was no history of headache, fever, altered sensorium, vision loss, trauma, diabetes or weakness of the limbs. On examination, there was right-sided third nerve palsy. The rest of the neurological and systemic examination was normal.

The patient's brain MRI was normal apart from pagetoid bony changes as evidenced by large well-defined lytic and sclerotic lesions in the skull along with diploic widening.

Blood investigations were normal except for markedly elevated alkaline phosphatase of 2171 μ/L (normal 40–125). The patient's skull X-ray revealed both osteolysis and osteosclerosis. His technetium bone scan showed marked uptake in the skull and left hip suggestive of polyostotic Paget's disease of bone.

He was treated with yearly zoledronic acid. He had complete resolution of his neurological deficit within 2 months with a significant decline in the alkaline phosphatase (1567 μ/L). At 2-year follow-up, his alkaline phosphatase was normal (84 μ/L) and bone scan revealed a marked regression of the disease.

Learning points
• Bone pains, deformities, fractures and neurological complications such as headache, hearing loss and nerve compression syndromes resulting in nerve palsies may be the initial presentation of Paget's disease of bone.

• Management of this condition usually involves maintaining adequate calcium and vitamin D nutrition and using antiresorptive agents such as zoledronic acid.

Read more here: http://casereports.bmj.com/content/2016/bcr-2016-214556.full
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