title: Skeletal fluorosis from instant tea.
abstract: BACKGROUND
  Skeletal fluorosis (SF) can result from prolonged consumption of well water with >4 ppm fluoride ion (F(-); i.e., >4 mg/liter). Black and green teas can contain significant amounts of F(-). In 2005, SF caused by drinking 1-2 gallons of double-strength instant tea daily throughout adult life was reported in a 52-yr-old woman.
  
  
  METHODS
  A 49-yr-old woman developed widespread musculoskeletal pains, considered fibromyalgia, in her mid-30s. Additionally, she had unexplained, increasing, axial osteosclerosis. She reported drinking 2 gallons of instant tea each day since 12 yr of age. Fluoxetine had been taken intermittently for 5 yr. Ion-selective electrode methodology quantitated F(-) in her blood, urine, fingernail and toenail clippings, tap water, and beverage.
  
  
  RESULTS
  Radiographs showed marked uniform osteosclerosis involving the axial skeleton without calcification of the paraspinal, intraspinal, sacrotuberous, or iliolumbar ligaments. Minimal bone excrescences affected ligamentous attachments in her forearms and tibias. DXA Z-scores were +10.3 in the lumbar spine and +2.8 in the total hip. Her serum F(-) level was 120 microg/liter (reference range, 20-80 microg/liter), and a 24-h urine collection contained 18 mg F(-)/g creatinine (reference value, <3). Fingernail and toenail clippings showed 3.50 and 5.58 mg F(-)/kg (control means, 1.61 and 2.02, respectively; p(s) < 0.001). The instant tea beverage, prepared as usual extra strength using tap water with approximately 1.2 ppm F(-), contained 5.8 ppm F(-). Therefore, the tea powder contributed approximately 35 mg of the 44 mg daily F(-) exposure from her beverage. Fluoxetine provided at most 3.3 mg of F(-) daily.
  
  
  CONCLUSIONS
  SF from habitual consumption of large volumes of extra strength instant tea calls for recognition and better understanding of a skeletal safety limit for this modern preparation of the world's most popular beverage.
authors.affiliation: Division of Bone and Mineral Diseases, Washington University School of Medicine at Barnes-Jewish Hospital, St Louis, Missouri, USA.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Whyte
authors.forename: William G
authors.initials: WG
authors.lastname: Totty
authors.forename: Vivienne T
authors.initials: VT
authors.lastname: Lim
authors.forename: Gary M
authors.initials: GM
authors.lastname: Whitford
mesh_terms: D001847:Bone Diseases / Q000209:etiology*; D005260:Female; D005459:Fluorides / Q000009:adverse effects*; D006801:Humans; D008875:Middle Aged; D010024:Osteoporosis / Q000209:etiology*; D013662:Tea / Q000009:adverse effects*
chemical_list: D013662:Tea; D005459:Fluorides