# More Than Just Bone Pain: A Case of Paget’s Disease, Seropositive Rheumatoid Arthritis, and Metabolic Dysfunction-Associated Steatohepatitis (MASH) in a Patient With Elevated Alkaline Phosphatase (ALP)

## TL;DR

A patient with elevated alkaline phosphatase was found to have three coexisting conditions: Paget’s disease, MASH, and rheumatoid arthritis.

## Contribution

Highlights a rare case of Paget’s disease, MASH, and RA presenting with elevated ALP.

## Key findings

- Elevated ALP was due to coexisting Paget’s disease, MASH, and RA.
- The case illustrates the diagnostic complexity of nonspecific ALP elevation.
- Combination of bone, liver, and autoimmune pathology was identified in one patient.

## Abstract

Paget’s disease of bone is a chronic skeletal disorder characterized by disorganized bone remodeling. Although often asymptomatic, it is frequently first detected through elevated alkaline phosphatase (ALP). Given ALP’s nonspecific nature, its elevation requires a comprehensive evaluation for hepatic, biliary, and bone pathology. We present a diagnostic challenge involving persistent ALP elevation in a patient ultimately found to have coexisting Paget’s disease, metabolic dysfunction-associated steatohepatitis (MASH), and seropositive rheumatoid arthritis (RA).