The images shown here are from a 75 years old man who was incidentally noted to have asymptomatic hypercalcemia (adjusted calcium level of 2.66 mmol/L and alkaline phosphatase (ALP) of 245 U/L). Heat stable ALP fraction was 0.15 (< 0.2 suggestive of bone origin). Parathyroid hormone was suppressed. Skeletal survey showed the following findings: cotton wool appearances of the skull; typical radiological features of osteosclerosis alternating with areas of osteolysis and bone expansion at the right hemi-pelvis. X-ray features were suggestive of Paget’s disease. Bone scan was performed and showed disease activity of the skull, right hemi-pelvis and left distal part of the femur. Whole body 18-flurodeoxyglucose body positron emission tomography (PET) did not show any evidence of an underlying malignancy. Because of the involvement of weight-bearing bones, the patient was prescribed with intravenous palmidronate, after which the serum calcium and ALP subsequently normalized. The patient is currently being regularly followed-up at the Geriatrics clinic with regular monitoring of the serum calcium and ALP levels.