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.
… 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 .
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