Abstract

Skeletal fluorosis is a metabolic bone disease caused by accumulation of fluoride and is generally associated with chronic exposure to fluoride-contaminated groundwater, a phenomenon endemic to developing countries. Whereas elevated water fluoride concentrations do not constitute a public health issue in the United States, emergence of skeletal fluorosis as a sequela of chronic recreational exposures has been described. In this case report, our 33-year-old male patient with a history of major depressive disorder and substance abuse was hospitalized for hyperkalemia and acute kidney injury discovered on routine bloodwork due to concomitant nonsteroidal anti-inflammatory drugs (NSAID) and antihypertensive use. Upon hospital admission, he was found to be anemic with a significantly elevated alkaline phosphatase. Given a history of low back pain in the setting of these laboratory abnormalities, lower spine and pelvic imaging revealed diffusely increased bone density and sclerosis. Hematologic evaluation ensued to include a peripheral smear and bone marrow biopsy. Given the patient’s history of computer cleaner inhalant abuse, serum and urinary fluoride levels were obtained. Serum fluoride returned within normal limits though urinary fluoride was increased. Bone marrow histopathology revealed prominent diffuse sclerosis which in conjunction with urinary fluoride levels and computer cleaner inhalant abuse history supported the diagnosis of skeletal fluorosis. Skeletal fluorosis in the United States is rare and presents with non-specific findings requiring a high index of suspicion based on a detailed patient history for expedient diagnosis.

Excerpt

… However, in recent years in the United States skeletal fluorosis has been described as a result of chronic recreational substance abuse with volatile anesthetics, fluoride-containing aerosolized computer cleaner, and surreptitious toothpaste ingestion [2].

References

1. Krishnamachari KA: Skeletal fluorosis in humans: a review of recent progress in the understanding of the disease. Prog Food Nutr Sci. 1986, 10:279-314.

2. Kurland ES, Schulman RC, Zerwekh JE, Reinus WR, Dempster DW, Whyte MP: Recovery from skeletal fluorosis (an enigmatic, American case). J Bone Miner Res. 2007, 22:163-170. 10.1359/jbmr.060912

3. Peicher K, Maalouf NM: Skeletal fluorosis due to fluorocarbon inhalation from an air dust cleaner. Calcif Tissue Int. 2017, 101:545-548. 10.1007/s00223-017-0305-0

4. Koroglu BK, Ersoy IH, Koroglu M, Balkarli A, Ersoy S, Varol S, Tamer MN: Serum parathyroid hormone levels in chronic endemic fluorosis. Biol Trace Elem Res. 2011, 143:79-86. 10.1007/s12011-010-8847-2

5. Tucci JR, Whitford GM, McAlister WH, Novack DV, Mumm S, Keaveny TM, Whyte MP: Skeletal fluorosis due to inhalation abuse of a difluoroethane-containing computer cleaner . J Bone Mine Res. 2017, 32:188-195. 10.1002/jbmr.2923

6. Ponce A, Oakes JA, Eggleston W: Acute skeletal fluorosis in the setting of 1,1-difluoroethane
abuse. Clin Toxicol. 2019, 57:374-375. 10.1080/15563650.2018.1527034

7. Cohen E, Hsu RY, Evangelista P, Aaron R, Rubin LE: Rapid-onset diffuse skeletal fluorosis from inhalant abuse: a case report. J Bone Joint Surg Case Connect. 2014, 4:e108. 10.2106/jbjs.cc.n.00085

Print PDF

• Related Studies :

  • Skeletal fluorosis in a resettled refugee from Kakuma refugee camp.

    “I suspected some contamination of the water of the much-frequented street pump in Broad Street, near the end of Cambridge Street”, said John Snow, about the contaminated water pump of the cholera outbreak of 1854, in London, UK.1 In September, 2015, a Somalian man aged 46 years presented to a refugee

  • Periarticular calcifications containing giant pseudo-crystals of francolite in skeletal fluorosis from 1,1-difluoroethane 'huffing".

    Highlights Diagnosing inhalant use disorder can be lifesaving. Chronic inhalation of F--containing vapors can cause skeletal fluorosis (SF). SF can elevate bone density and cause periostitis and ectopic calcification. Francolite is a carbonate-rich fluorapatite. Periarticular calcification in SF can comprise giant pseudo-crystals of francolite. Inhalant use disorder is a psychiatric

  • Studies on fluorosis in Mehsana District of North Gujarat.

    A survey was conducted in eighteen fluoride endemic villages in Mehsana District of North Gujarat (India). The individuals afflicted with fluorosis were examined for apparent mottled teeth and skeletal complications. Samples of urine and blood of these individuals along with drinking water were collected and compared with samples obtained from

  • Skeletal fluorosis in Vavuniya District: an observational study.

    Background: The WHO recommended safe upper limit for fluoride in drinking water is 1.5 mg/l. Groundwater sources in many parts of Sri Lanka often exceed this limit. The high fluoride content of groundwater and high environmental temperatures in Vavuniya District predispose to pre-skeletal fluorosis and skeletal fluorosis in adults. Objectives: To

  • Skeletal fluorosis from brewed tea

    BACKGROUND:  High fluoride ion (F(-)) levels are found in many surface and well waters. Drinking F(-)-contaminated water typically explains endemic skeletal fluorosis (SF). In some regions of Asia, however, poor quality "brick tea" also causes this disorder. The plant source of brick, black, green, orange pekoe, and oolong tea, Camellia

• Related FAN Content :

  • Skeletal Fluorosis: The Misdiagnosis Problem

    It is a virtual certainty that there are individuals in the general population unknowingly suffering from some form of skeletal fluorosis as a result of a doctor's failure to consider fluoride as a cause of their symptoms. Proof that this is the case can be found in the following case reports of skeletal fluorosis written by doctors in the U.S. and other western countries. As can be seen, a consistent feature of these reports is that fluorosis patients--even those with crippling skeletal fluorosis--are misdiagnosed for years by multiple teams of doctors who routinely fail to consider fluoride as a possible cause of their disease.

  • "Pre-Skeletal" Fluorosis

    As demonstrated by the studies below, skeletal fluorosis may produce adverse symptoms, including arthritic pains, clinical osteoarthritis, gastrointestinal disturbances, and bone fragility, before the classic bone change of fluorosis (i.e., osteosclerosis in the spine and pelvis) is detectable by x-ray. Relying on x-rays, therefore, to diagnosis skeletal fluorosis will invariably fail to protect those individuals who are suffering from the pre-skeletal phase of the disease. Moreover, some individuals with clinical skeletal fluorosis will not develop an increase in bone density, let alone osteosclerosis, of the spine. Thus, relying on unusual increases in spinal bone density will under-detect the rate of skeletal fluoride poisoning in a population.

  • Fluoride & Osteoarthritis

    While the osteoarthritic effects that occurred from fluoride exposure were once considered to be limited to those with skeletal fluorosis, recent research shows that fluoride can cause osteoarthritis in the absence of traditionally defined fluorosis. Conventional methods used for detecting skeletal fluorosis, therefore, will fail to detect the full range of people suffering from fluoride-induced osteoarthritis.

  • Fluoride & Spinal Stenosis

    Spinal stenosis is a narrowing of the spaces in the spine that results in pressure being placed on the spinal cord and/or nerve roots. Although stenosis can develop without symptoms, it may produce numbness, tingling, pain and difficulty in walking, as well as a heavy/tired feeling in the legs. It is estimated that 250,000 to 500,000 Americans currently have symptoms of spinal stenosis. Skeletal fluorosis is one cause of stenosis.

  • Variability in Radiographic Appearance of Skeletal Fluorosis

    Osteosclerosis (dense bone) is the bone change typically associated with skeletal fluorosis, particularly in the axial skeleton (spine, pelvis, and ribs). Research shows, however, that skeletal fluorosis produces a spectrum of bone changes, including osteomalacia, osteoporosis, exostoses, changes resulting from secondary hyperparathyroidism, and combinations thereof. Although the reason for this radiographic variability is not yet fully understood, it is believed to relate to the dose of fluoride consumed, the individual's nutritional status, exposure to aluminum, genetic susceptibility, presence of kidney disease, and area of the skeleton examined.