Clinical presentation:
42 year old male with an 8 month history of increasing back pain. Had been bed-ridden for the last 3 weeks. The serum calcium was markedly elevated.

The plain film view of the pelvis shows extensive patchy bone destruction. The lytic areas undermine the cortex at various points, but the cortex is intact with no visible lamellar reaction. The patient is constipated.

There is extensive patchy osteoporosis of the lumbar vertebrae and visible destructive collapse of the second lumbar vertebra, having a concave upper margin in the lateraL view. Its pedicles are relatively intact. Fine granularity is a biproduct of the TV camera, used to collect this case (1997 technology).

There are multiple small lytic areas in the skull vault. The margins of vault and pituitary fossa appear intact. Diploic vessel pattern is preserved.

The bone scan shows uptake in the anterior ends of right 3-5th ribs and left 5 and 6th ribs. The lumbar spine uptake is patchy and totally inconsistent with the extent of bone destruction in the plain films. The patient is young for this condition, but this appearance is typical of the pathology. The rib uptake may be related to undiagnosed healing fractures. Normal renal excetion shows the location of the kidneys and bladder.