P4793 - An Unusual Case of Cured Hepatitis C But Persistent Liver Enzyme Elevations Leading to Diagnosis of Paget’s Disease

Tobias W. Cox, , Stuart Gordon, MD, Syed-Mohammed Jafri, MD
Henry Ford Health, Detroit, MI

Introduction: Raised serum alkaline phosphatase in the setting of pre-existing liver disease may delay appropriate diagnosis of underlying bone disease.

Case Description/Methods: A 73-year-old male patient with polycystic liver presented to the hepatology clinic because of a positive anti-HCV test and confirmed HCV viremia. His past medical history also included right shoulder and bilateral knee osteoarthritis. Laboratory studies showed elevation of aspartate aminotransferase/alanine aminotransferase (AST/ALT) at 41/40 U/L and a raised serum alkaline phosphatase (ALP) of 272 IU/L. Liver stiffness as assessed by transient elastography showed F0-F1 fibrosis and moderate hepatic steatosis. Computed tomography imaging demonstrates smooth liver contour and hepatic cysts measuring a maximum of 2.5 cm in diameter without biliary dilation. The patient was treated with oral glecaprevir-pibrentasvir for eight weeks and achieved a sustained viral response (SVR).

At follow-up after achieving SVR, the alkaline phosphatase remained elevated at 328 IU/L. Additional testing revealed a positive antinuclear antibody titer of 1:160, negative liver kidney microsomal (LKM) antibodies, negative mitochondrial M2 antibodies, negative smooth muscle antibodies, elevated immunoglobulin A, and a normal gamma-glutamyl transferase value. Alkaline phosphatase isozymes showed a high percentage of bone isozyme at 74%, and a low percentage of liver isozyme at 15%. A technetium bone scan shows increased radiotracer uptake in the left hemipelvis, left femoral head, L1 and L4, confirming Paget’s disease of those areas. The patient was referred to his primary team for further management and consideration of bisphosphonate therapy.

Discussion: Paget’s disease of the skeletal system involves a faulty bone remodeling process that can cause fragile and oddly shaped bones to develop. Patients with Paget’s disease often have no symptoms, with the disease being discovered incidentally on imaging. When patients do have symptoms, these may include fractures, bone and joint pain, or musculoskeletal deformities. Because pain secondary to Paget’s disease can be misdiagnosed as arthritis, it should be ruled out in cases of unexplained elevated ALP, especially in older patients at risk of falls and fractures. In this case, underlying chronic viral hepatitis and polycystic liver delayed the investigation for non-hepatic etiologies of raised serum ALP.


Disclosures:


Tobias W. Cox, , Stuart Gordon, MD, Syed-Mohammed Jafri, MD. P4793 - An Unusual Case of Cured Hepatitis C But Persistent Liver Enzyme Elevations Leading to Diagnosis of Paget’s Disease, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.