The patient was admitted with the signs and symptoms of paralysis of the arms and legs and diffuse bone and low-back pain.
The patient was admitted with the signs and symptoms of paralysis of the arms and legs and diffuse bone and low-back pain. She also complained of forgetfulness of 2 years' duration and loss of concentration when performing detailed functions in daily life. Laboratory results were within the normal limits.
Plain radiography of the skeletal system demonstrated sclerotic changes in both the axial and appendicular skeleton (Fig. 1). On computed tomography (CT), the bones showed prominent cortical thickening and increased density with irregular contours. Bony excrescences were detected in both the pelvic bones and the lower extremities. The sacroiliac joints were narrow(Fig. 2).
Magnetic resonance imaging (MRI) showed prominent signal losses in all bones on spin-echo T1- and gradient-echo T2*-weighted images. On thoraco-lumbar MRI, the vertebrae and sternum showed prominent hypointense signals on both T1- and T2*-weighted images. The intervertebral disc spaces were decreased and multiple prolapses were demonstrated (Fig. 3). The medullary canal was narrowed by bony excrescences and by the ossified posterior longitudinal ligament. Axial MRI sections through the pelvic bones showed hypointense signals on both T1- and T2*-weighted images (Fig. 4). Bony excrescences were also demonstrated on MRI. On cranial MRI, the brain showed atrophic changes, particularly prominent bilaterally at the perislyvian areas, despite the patient's young age (Fig. 5).
Fluorosis is related to high concentrations of fluoride present in drinking water, surrounding soil or produced by coal burning. It is endemic in certain parts of the world, including the eastern part of Turkey. Its effects on the skeletal system and teeth are well known. Fluoride directly stimulates bone formation in vivo and fluoroapatite formation (1). Involvement of the axial skeleton is characteristic. Fluoride is retained in the bones and induces hardening of all the bones, including the spine. Increased trabecular condensation creates an extremely radiodense appearance throughout the thorax, vertebral column and pelvis. The skull and tubular bones are generally relatively spared. However, in this case the changes in tubular bones were also very prominent. This can be attributed to high exposure or a long duration of exposure to fluoride (1).
Vertebral osteophytosis may be very prominent and can encroach on the spinal canal and vertebral foramina. Thus neurological symptoms are frequently seen, as in this case.
Bony excrescences develop at the sites of ligamentous insertions (iliac crests, ischial tuberosities and inferior margins of ribs). In the appendicular skeleton osteopaenia with or without recovery lines may be an early finding. Osteophytosis, ligament calcification and periosteal thickening can also be seen.
The common findings of osteosclerosis, osteophytosis, ligamentous calcification and periostitis can also be seen in many other diseases. When these findings are detected in a patient coming from a non-endemic region, the following differential diagnoses should be considered: skeletal metastasis, especially prostate metastasis; myelofibrosis; mastocytosis; renal osteodystrophy; Paget's disease; pachydermoperiostitis; and diffuse skeletal hyperostosis. The demonstration of a primary malignancy in the prostate and the age of the patient can provide important clues in prostate carcinoma. Metastatic disease is less generalised, less symmetric, and most frequently involves the axial skeleton. Myelofibrosis is seen in middle-aged or elderly patients. It is characterised by bone marrow fibrosis and splenomegaly (2). Mastocytosis may produce local or diffuse sclerosis associated with hepatosplenomegaly. Paget's disease causes a characteristic coarsened trabecular pattern (3). Pachydermoperiostosis is easily differentiated by digital clubbing, skin changes, enlargement of the paranasal sinuses, and the predominant feature of periostitis extending to the epiphysis (4). Osteosclerosis is a well-known feature of renal osteodystrophy. It predominates in the axial skeleton and is most prominent in the superior and inferior portions of the vertebral bodies (rugger-jersey spine). In diffuse idiopathic skeletal hyperosteosis, ligament calcification and ossification is present along the anterolateral portion of at least four contiguous vertebral bodies. Sclerotic changes, like dripping candle wax in the medial portion of the tibia, can mimic melorheostosis, as in this case. But in melorheostosis this sign especially affects the outer rather than inner surface of the affected limb. In contrast to fluorosis, melorheostosis most commonly affects the tubular bones (5).
Fluorosis can affect many other body systems, including the respiratory, urinary and central nervous systems. The blood-brain barrier fails to exclude fluoride from nervous tissue and, consequently, this ion accumulates in the brain. In affected patients many kinds of neurological symptoms have been reported, such as partial paralysis of the arms and legs, headache, spasticity in the extremities, visual disturbance and mental retardation. In this case, despite the patient's young age, the brain showed significant atrophic changes.
Fluorosis
Based on the provided X-ray, CT, and MRI images, the following main features are observed:
Combining the patient’s profile (35-year-old female), clinical manifestations (quadriplegia, bone pain), and imaging features (increased bone density, osteophytes, and signs of nerve compression), the differential diagnoses may include:
Taking into account the patient’s environmental background (possibly from or long-term residence in a high-fluoride area), clinical manifestations (bone pain, limb paralysis reflecting neurological involvement), and imaging features (widespread bone sclerosis, dense vertebrae and pelvic bones, and brain atrophy suggesting neurological implications), the most likely diagnosis is:
Skeletal Fluorosis (Fluoride Poisoning).
If fluorine levels or bone metabolism indices are not yet confirmed, measuring serum and urinary fluoride levels, along with other bone metabolism markers, can help verify the diagnosis.
During rehabilitation, considerations must be given to bone pain, altered bone structure, and neurological involvement. An individualized and gradual approach to exercise is advised:
Throughout the entire rehabilitation process, pay special attention to:
This report is a reference medical analysis based on the provided medical history and imaging data. It cannot replace in-person clinical diagnosis and professional medical treatment. For final decisions regarding diagnosis and treatment, please consider clinical examinations, laboratory tests, and the evaluation of specialized physicians.
Fluorosis
