Asymptomatic Elevated Serum Alkaline Phosphatase – Diagnosis or Path to Diagnosis – Morbus Pagets (Cace Report)

Case Report

Ljiljana Tadić, Nikola Krstić


Morbus Paget (osteitis deformans) is a non-inflammatory, metabolic disease of the skeleton, of unknown etiology, characterized by bone remodeling caused by excessive bone resorption by osteoclasts and a compensatory increase in osteoblast activity.

The paper aimed to present a patient with an asymptomatic elevated value of alkaline phosphatase and the differential diagnostic dilemmas that accompanied this laboratory abnormality.

It is a 62-year-old man referred to a rheumatologist for a laboratory-verified elevated serum alkaline phosphatase (ALP) value of 269 I/U. Subjectively, he had neither complaints nor bone pain. He denied other system complaints. As part of the regular cardiological check-up, laboratory diagnostics were performed and an elevated ALP value was seen, which is why he was referred to a rheumatologist. Other hematological and biochemical parameters, as well as tumor markers, were within reference limits, including serum Ca, P, 25(OH)D, and PTH. MSCT examination of the pelvis in the projection of the wing of the right iliac bone showed a round osteosclerotic change with a diameter of 19 mm, which initially could indicate a secondary deposit. The sacrum was completely altered by numerous osteosclerotic changes resembling secondary deposits. In skeletal scintigraphy, the finding corresponded to the presence of secondary deposits in L5, sacrum, wing of the left iliac bone, left SI joint, and wing of the right iliac bone. Biopsy of changes in the sacrum, and pathohistological findings showed a metabolic bone disease of the type osteitis deformans – Morbus Paget.

Therapy with bisphosphonate and vitamin D for the next year, and then only with vitamin D, resulted in normal values of Ca, P, ALP, and 25(OH)D with a good general condition of the patient.

It is necessary to perform complete diagnostics as part of the investigation of asymptomatic unclear conditions accompanied by biochemical abnormalities.

Key words: alkaline phosphatase, Paget`s disease, bone biopsy, bisphosphonates

Ful text 


  1. Nebot Valenzuela E, Pietschmann P. Epidemiology and pathology of Paget’s disease of bone – a review. Wien Med Wochenschr 2017; 167(1–2): 2–8.
  2. Klemm P, Dischereit G, von Gerlach S, Lange U. Morbus Paget des Knochens – eine aktuelle Übersicht zu Klinik, Diagnostik und Therapie [Paget’s disease of bone-a current review of clinical aspects, diagnostics and treatment]. Z Rheumatol 2021; 80(1): 48–53.
  3. Rabjohns E, Hurst K, Ghosh A, Cuelar M, Rampersad R, Tarrant R. Paget’s Disease of Bone: Osteoimmunology and Osteoclast Pathology. Curr Allergy Asthma Rep 2021; 21(4): 23.
  4. Merlotti D, Rendina D, Cavati G, Abate V, Falchetti A, Mingiano C, Nuti R, Gennari L. Drug treatment strategies for paget’s disease: relieving pain and preventing progression. Expert Opin Pharmacother 2023; 24(6): 715–27.