History A 74-year-old woman presented with multifocal bone
pain, including
pain in multiple ribs, bilateral shoulders, and bilateral hips. The
pain began several months before presentation and was quite severe, ultimately necessitating control with
narcotics. At examination, strength in both lower extremities was slightly
reduced, sensation and reflexes were intact, and range of motion was full, though painful. There were no notable constitutional symptoms of
fever or
weight loss. Laboratory work-up was remarkable for elevated
alkaline phosphatase level (277 U/L [4.6 mkat/L]). The patient had undergone left
lung transplantation 8 years prior for
pulmonary fibrosis. A thorough pulmonary work-up for the cause of
fibrosis, which included gathering an exposure, occupational,
allergy, and previous infectious history, and a rheumatoid work-up were negative. The patient's posttransplantation course was complicated by
bronchiolitis obliterans from chronic rejection and by recent
pulmonary embolism, for which she was undergoing anticoagulation
therapy at the time of presentation. Additionally, the patient experienced repeated pulmonary
infections with Aspergillus, leading to multiple hospitalizations and long-term antifungal prophylaxis with
voriconazole. A bone scan from an outside hospital was reviewed, and further imaging was performed.