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Abstract

Case Presentation: A 68-year-old Indian gentleman presented to our general practice clinic complaining of lower back pain with shooting pain radiating to the right posterior leg. The general practitioner ordered an X-ray of the lumbosacral spine and biochemistry. The X-ray showed sclerosis and a picture frame appearance in the L2 vertebra with degenerative changes in the rest of the spine (Fig. 1 A and Fig. 1 B). Biochemistry showed an adjusted calcium at 2.56 mmol/L (normal, 2.15 to 2.50 mmol/L), phosphate at 1.3 mmol/L (normal, 0.8 to 1.4 mmol/L), alkaline phosphatase (ALP) at 140 U/L (normal, 40 to 120 U/L), heat-stable ALP at 4% (<20% signifies bone origin), parathyroid hormone at 5.2 mmol/L (normal, 0.8 to 6.6 mmol/L), and 25-hydroxyvitamin D (total) at 20 μg/L (normal, 30 to 50 μg/L). He was referred to the endocrinologist for further management. A technetium 99m-methylene diphosphate triphasic bone scan showed intense tracer uptake in the entire L2 vertebra, including the posterior elements (spinous process) with no other focal increased tracer uptake at other sites (Fig. 2). What is the diagnosis? Fig. 2 View Large Image Figure Viewer