A 14-year-old boy with prolonged history of backache. Plain radiographs of thorax and spine were performed. He belonged to an endemic area for fluorosis.
Chest radiographs revealed increased bone density, thick angulated ribs reducing intercostal heights (Fig. 1), smaller and wider vertebral bodies with bridging osteophytosis (Fig. 2 and 3) and ossification of sacrospinous ligaments (Fig. 3).
Endemic skeletal fluorosis is a chronic metabolic disorder of bone caused by the ingestion of large amounts of fluoride in the local drinking water. The accumulated fluoride increases metabolic turnover and impairs collagen synthesis of the bone resulting in deposition of osteoid tissue within the bony trabeculae and cortex, with extension into muscle attachments [1]. Involvement of the axial skeleton is characteristic, and changes are most marked in the spine, pelvis, and ribs [2-5]. The radiologic features include increased bone density; blurring of trabeculae; compact bone thickening; periosteal bone formation; and ossification of the attachments of tendons, ligaments, and muscles [6-8]. Increased bone density alone is a nonspecific finding seen in a wide variety of disorders, including metastases, myelofibrosis, paget’s disease, hemoglobinopathies, renal osteodystrophy, and congenital disorders [9,10]. Similarly, vertebral osteophytosis with soft-tissue calcification and ossification can occur in spondylitis deformans, diffuse idiopathic skeletal hyperostosis, ankylosing spondylitis, psoriasis, other spondyloarthropathies, acromegaly, neuropathy, and alkaptonuria and is not diagnostic when seen alone [9,10]. Proliferative changes at ligament and tendon insertions and periostitis may also occur in diffuse idiopathic skeletal hyperostosis, hyperparathyroidism, X-Iinked hypophosphatemic osteomalacia, and plasma cell dyscrasia [2]. Combination of radiological features particularly characteristic ligament calcifications and a history of long-term heavy exposure to fluoride are very important in the diagnosis of skeletal fluorosis [2,9-11]. A history of exposure is essential for early diagnosis [12]. Various combinations of osteosclerosis, osteomalacia, and osteoporosis, as well as exostosis formation, have also been reported [9].
Skeletal flurosis
1. The PA chest X-ray shows increased bone density in the ribs, with clear rib contours but blurred trabecular structures in certain areas (as indicated by the arrow).
2. In the lateral and AP views of the lumbar spine, the vertebral bodies show increased bone density, with lip-like or osteophyte-like proliferations at the vertebral margins, some displaying pronounced sclerosis.
3. There is thickening of the cortical bone, and calcification or ossification signs at certain ligament or tendon attachment sites (e.g., lumbar facet joints, pelvis, vertebral attachments), corresponding to possible soft tissue calcification or ligament ossification.
4. Overall imaging findings indicate diffuse osteosclerosis, especially prominent in the spine and ribs.
Combining the patient’s long-term residence in a high-fluoride area, clinical symptoms (chronic back pain), and radiological findings of diffuse sclerosis and ligament ossification in the spine and ribs, the most likely final diagnosis is:
Fluorosis (endemic fluoride poisoning)
For further confirmation, additional tests such as serum and urine fluoride levels, bone density evaluation, and other imaging or laboratory tests can be conducted.
1. Remove or reduce fluoride exposure: If the fluoride content in drinking water or the surrounding environment exceeds the standard, it is essential to lower fluoride intake by changing the water source, installing defluoridation devices, or other relevant measures.
2. Nutritional support and pharmacological interventions:
• Adequate intake of calcium and vitamin D to help improve bone metabolism.
• For patients with significant symptoms, under professional medical guidance, consider the use of non-steroidal anti-inflammatory drugs (NSAIDs) to relieve pain.
3. Rehabilitation and Exercise Prescription:
Disclaimer: The above content is a reference analysis based on current imaging and clinical information. It does not substitute for in-person consultation or professional medical advice. If you have any questions, please seek medical attention or undergo further testing in a timely manner.
Skeletal flurosis
