My husband is a 48 yr old male who has no regular doctor. He goes to the ER with kidney stone pain. He has a 25 yr history of kidney stones. CT scan shows three larger stones distributed between the two kidneys and one stone in route to the bladder. Additional finds of the CT scan include diverticulosis and most notably sclerotic bones involving vertebral bodies L1, L2, and L4 as well as sacrum and pelvis all having the appearance of osteoblastic metastatic disease. Radiologist suggested prostate cancer.
Referral to urology and continued tests. PSA is normal. DRE finds prostate enlargement but not abnormal. Additional blood tests of comprehensive metabolic panel, LH level, and CBC find only elevated ALP of 223 on a range of 38-110 and platelet estimation of low normal. Complete liver panel shows only elevated ALP of 228.
Urologist ordered bone scan finding: large area of increased radiotracer activity in left calcarium, asymmetric uptake in proximal right humerus, foci of increased uptake in T5, T8, L1, L2 and L4 areas of spine – moderate to intense. Increased uptake in pelvis including right iliac bone, left sacrum and acetabular regions bilaterally, more intense on the left and right. Left kidney is larger than the right. Radiologist noted that CT appearance was not suggested of Paget’s Disease and again pointed to metastatic disease.
Urologist also ordered chest x-ray finding mild bibasilar atelectasis or scar and mild T10 compression fracture, age indeterminate.
The kidney stone in route took six weeks to pass. The urologist may be referring to oncology, at patient’s wife’s request, while scheduling procedures for the stones in the kidneys.
Other Patent History:
Similar tests done three years prior, by a doctor no longer seen by patient, showed the following: ALP 209 (range 40-115), Bone isoenzyme 84 (range 28-66) Liver isoenzyme 13 (range 25-69), and intestine and placental isoenzymes were within range. PTH showed the parathyroid to be within range. Serum calcium normal. 24 hr urine test showed calcium 335 (range <300 for males) and uric acid normal. Lipid panel showed high trigycerides, total cholesterol, LDL, and CHOL/HDLC ratio. At this time ALT was also high at 75 (range 30-65) and globulin was low at 2.8 (range 3.0 - 4.8).
Patient was born with clubbed right foot and impacted leg is 1.75 inches shorter that the other. This has resulted in a life time of back and hip pain treated by chiropractors. Pain has increased over the years – patient says “it is not the years, it’s the mileage”. Wife notes that he has lost some weight recently.
Patient history also includes drug and alcohol abuse and a history of “high liver enzymes” and upper right quadrant pain resulting in extensive liver testing. Testing done between 2003 and 2005 included liver biopsy (normal), monthly blood panels (showing increased ALP, ALT, negative for all hepatitis). Ultrasounds of the liver and gall gladder done with no adverse findings. Abdominal ultrasound in 2004 found mild intrahepatic biliary duct dilation and splenomegaly. Other notable items include hiatal hernia (EGD in 2004) and GERD.
So, what other than kidney stones is wrong with this patient? The urologist doesn’t think it is prostate cancer. The bone legions are sclerotic and blastic, not lytic. And on a side note, the skull had a portion with little or no uptake. This was not noted by the radiologist.