Skeletal fluorosis from brewed tea

Background: High fluoride ion (F ^-) levels are found in many surface and well waters. Drinking F ^--contaminated water typically explains endemic skeletal fluorosis (SF). In some regions of Asia, however, poor quality "brick tea" also causes this disorder. The plant source of brick, black, green, orange pekoe, and oolong tea, Camellia sinensis, can contain substantial amounts of F ^-. Exposure to 20 mg F ^- per day for 20 yr of adult life is expected to cause symptomatic SF. High F ^- levels stimulate osteoblasts and enhance bone apposition but substitute for OH ^- groups in hydroxyapatite crystals and thereby result in skeletal fragility and perhaps lead to secondary hyperparathyroidism. Beginning in 2005, we showed that daily consumption of 1-2 gallons of instant tea made from this plant can lead to SF. Aim: We describe a 48-yr-old American woman who developed SF from brewed tea. Patient and Methods: Our patient had elevated bone mineral density revealed by dual-energy x-ray absorptiometry (spine Z-score, +9.9), severe chronic bone and joint pain, and kyphosis after consuming 1-2 gallons of brewed orange pekoe tea daily for more than three decades. F ^- levels were high in her serum, urine, and clippings of fingernails and toenails, as well as in our reproduction of her beverage. Renal function was normal. She had vitamin D deficiency. Elevated serum PTH levels were unresponsive to adequate vitamin D supplementation. Pain resolved over several months when she stopped drinking tea and continued ergocalciferol. Conclusion: Our patient shows that SF can result from chronic consumption of large volumes of brewed tea.