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An 87-year-old asymptomatic woman was incidentally found to have an elevated alkaline phosphatase level (216 IU per liter; upper limit of the normal range, 136). The remainder of the liver-function studies, metabolic profile, lactate dehydrogenase levels, and blood-cell counts were normal. The serum calcium level was normal (8.5 mg per deciliter [2.1 mmol per liter]), as was the serum albumin level. There were no palpable skull defects or masses. Bone scanning revealed marked uptake in the calvaria (Panel A). Skull radiographs demonstrated a large, round, lucent area in the left parietal bone (Panel B). Computed tomography of the skull confirmed the presence of a 5-cm lytic abnormality involving the left parietal bone that was well differentiated from normal-appearing calvarial bone (Panel C). The area was decalcified and thinner than normal and had slightly irregular trabeculae. There was no associated soft-tissue abnormality. The findings were consistent with the presence of osteoporosis circumscripta. This lytic phase of Paget's disease is often subclinical and progresses slowly. However, neurologic symptoms, particularly hearing loss with petrous-bone involvement, may occur.
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