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Table of Contents
CLINICAL IMAGES
Year : 2021  |  Volume : 18  |  Issue : 1  |  Page : 66-67

Skeletal fluorosis: Problem that runs deep


1 Department of Endocrinology, Shree Narayana Institute of Medical Superspeciality, Nanded, Maharashtra, India
2 Department of Nephrology, Abhyuday Lifecare Superspecialitry Hospital, Nanded, Maharashtra, India
3 Department of Biochemistry, Shree Narayana Institute of Medical Superspeciality, Nanded, Maharashtra, India

Date of Submission13-Jan-2021
Date of Decision15-Feb-2021
Date of Acceptance20-Feb-2021
Date of Web Publication02-Mar-2021

Correspondence Address:
Chaitanya Yerawar
Department of Endocrinology, Shree Narayana Institute of Medical Superspeciality, Nanded, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_4_21

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How to cite this article:
Yerawar C, Kabde A, Durugkar S, Deokar P. Skeletal fluorosis: Problem that runs deep. Apollo Med 2021;18:66-7

How to cite this URL:
Yerawar C, Kabde A, Durugkar S, Deokar P. Skeletal fluorosis: Problem that runs deep. Apollo Med [serial online] 2021 [cited 2021 Apr 11];18:66-7. Available from: https://www.apollomedicine.org/text.asp?2021/18/1/66/310641

Skeletal fluorosis is a worldwide health problem.[1] In India, fluorosis is endemic in many states, the most common etiology being consumption of fluoride-rich water derived from deep bore wells.[1],[2] A 38-year-old male presented to the endocrinology outpatient department with multiple joint pain and restricted movement at elbow joint for the past 8 years. On physical examination, he had noticeable brown-discolored and mottled enamel [Figure 1]a. X-ray of the forearm was suggestive of interosseous membrane calcification and periosteal new bone formations [Figure 1]b. Ossification of the interosseous membrane and brown-discolored mottled enamel clinched the diagnosis of fluorosis. On further enquiry, the patient revealed similar brown discoloration of teeth in other family members. X-ray of the pelvic region, cervical spine, knee joint, and ankle joint revealed typical features of skeletal fluorosis [Figure 1]c, [Figure 1]d, [Figure 1]e, [Figure 1]f. His biochemical evaluation was as follows: serum calcium 8.74 mg% (8.8–10.2 mg%), phosphorus 2.5 mg% (2.5–4.5 mg%), alkaline phosphatase 1049 U/L (80–306 U/L), 25(OH) vitamin D 42 ng/ml (30–100 ng/mL), creatinine 1.4 mg/dL (0.6–1.4 mg/dL), serum fluoride 155.7 mg/L (0.02–0.05 mg/L), urine fluoride 45.4 (0.2–1.1 mg/L), and water fluoride 5.77 mg/L (up 0.02–0.05 to 1.0 mg/L) (ion liquid chromatographic method). Other routine biochemical investigations were within normal limits. Estimation of fluoride in drinking water and skeletal radiographs alone are enough to confirm the diagnosis of fluorosis.[2] Hence, based on his clinical, biochemical, and radiological features, diagnosis of fluorosis was confirmed. The patient was advised to avoid fluoridated water, and he was treated with calcium, ascorbic acid, and Vitamin D supplementation. This case highlights the long and painful journey many patients endure due to delay in diagnosis, resulting from a condition which is preventable if detected early. Regular dental examination in the endemic area can be crucial for early diagnosis before skeletal changes sets in the patient, family, and the community.
Figure 1: (a) Dental fluorosis. Brown discolored and mottled enamel. (b) Radiograph of the forearm showing interosseous membrane calcification and periosteal new bone formations. (c) Radiograph of the pelvis showing increased bone density along with calcification of posterior sacroiliac ligament (arrows). (d) Lateral radiograph of the cervical spine showing diffuse bone condensation with calcification of the posterior longitudinal ligaments (arrows). (e) Radiograph of the knee joint showing bony exostosis over femur, tibia and fibula (arrows). (f) Radiography of the ankle joint revealed multiple exostoses (arrows)

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Teotia SP, Teotia M, Singh KP. Highlights of Forty Years of Research on Endemic Skeletal Fluorosis in India. 4th International Workshop on Fluorosis Prevention and Defluoridation of Water. Colombo, Sri Lanka; March 2–6, 2004.  Back to cited text no. 1
    
2.
Sellami M, Riahi H, Maatallah K, Ferjani H, Bouaziz MC, Ladeb MF. Skeletal fluorosis: Don't miss the diagnosis! Skeletal Radiol 2020;49:345-57. doi: 10.1007/s00256-019-03302-0.  Back to cited text no. 2
    


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