Clinical Images: Delayed presentation of skeletal fluorosis: an uncommon case of increased bone density

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The patient, a 51-year-old man with a history of bariatric surgery (current body mass index of 30 kg/m2), was evaluated for high bone density on a dual-energy x-ray absorptiometry scan, which showed T-scores of +6.8 SD at the lumbar spine, +2.0 at the femoral neck, and +3.8 at the total hip. Lumbar and pelvic computed tomography scans revealed marked osteosclerosis (A, B, and E), ossification of the anterior longitudinal ligament (A and C), and areas of focal ossification (D–F). Hypervitaminosis A or D, hypoparathyroidism, hypophosphataemic osteomalacia, chronic kidney disease, hepatitis C, and exposure to cadmium were ruled out. No signs of hematologic disease were found in the complete blood count, and no particular allergies were identified. When asked specifically, the patient recalled taking calcium and fluoride supplements every morning from birth until aged 15 years. Skeletal fluorosis was diagnosed following an expert radiologic review of the case. Classic radiologic features include osteosclerosis, periosteal bone formation, ossification of the enthesis, interosseous membrane calcification, and ossification of the posterior longitudinal ligament.1 Diagnosis is usually made while fluor intoxication is still active. In our patient, the intoxication stopped several decades ago, yet the radiologic abnormalities persisted. His serum fluoride level was normal. Axial abnormalities may persist for decades due to the seven-year half-life of fluoride deposited in bone.2 Disclosure form. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

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