Abstract Introduction Paget’s bone disease is typically seen in elderly patients, and bisphosphonate (BP) therapy is the first-line treatment for achieving remission. However, in patients with end-stage renal disease (ESRD), it may be overlooked due to its radiologic and biochemical resemblance to secondary hyperparathyroidism-related bone lesions. This case underscores the diagnostic and therapeutic difficulties that may arise when Paget’s disease coexists with ESRD. Clinical Case A 61-year-old male shuttle driver from Türkiye, with a medical history of ESRD attributed to hypertensive nephropathy since 2017, was referred to the endocrinology clinic in October 2024. A referral was initiated for incidentally identified expansile lesion in the right femoral head, observed on imaging during follow-up for prostate adenocarcinoma, first diagnosed in 2021. The patient has had peritoneal dialysis since 2018 and has been diagnosed with secondary hyperparathyroidism, treated with cinacalcet due to rising parathormone levels during follow-up. He had no familial history of bone disease. He experienced no discomfort, morning stiffness, or trouble walking, localized bone pain, hearing loss, or history of fractures for three years. The physical examination was unremarkable, with the exception of a peritoneal dialysis catheter. Blood Pressure:140/90 mmHg, height:168 cm, weight:80 kg BMI:28,3 kg/m2 Table-1 showed laboratory results at the time of presentation. In 2021, a surveillance MRI for prostate cancer identified heterogeneous intramedullary bone marrow in the trochanteric and subtrochanteric regions, accompanied by irregular cortical thickening. The patient did not undergo a biopsy and was treated conservatively with radiotherapy and hormonal therapy for prostate cancer. In 2023, the patient resumed follow-up, and further evaluation of the bone lesion was conducted using a PET-CT scan due to his prostate malignancy. The scan revealed FDG uptake in the femoral neck and trochanteric region, indicating an active bone lesion. Bone scintigraphy conducted in August 2024 demonstrated significant uptake localized to the proximal right femur, consistent with Paget’s disease. (Figure-1) The assessment of bone mineral density showed:L1–L4: 1.423 g/cm², T-score: +1.5; left femoral neck: 1.361 g/cm², T-score: +2.2 The differential diagnosis comprised Paget’s disease, secondary hyperparathyroidism with bone lesions, and metastatic bone disease. The imaging findings, absence of systemic symptoms, and presence of a monostotic lesion corroborated the diagnosis of Paget’s disease. Table -2 showed time course of laboratory findings. BP therapy was avoided due to the elevated risk of vascular and soft tissue calcification. A multidisciplinary discussion with nephrology was held to optimize management. Conclusion This case highlights the infrequency of Paget’s disease among dialysis patients and the diagnostic difficulties arising from its similarities to Brown tumors of hyperparathyroidismFigure 1:Radiography & Scintigraphy of Paget’s disease at right femur, shown at the arrow point Table 1:Laboratory results at the time of presentation Table 2:Time course of laboratory findings
Yavuz et al. (Thu,) studied this question.