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A 40-year-old woman, resident of Eastern Uttar Pradesh, India, reported 3 years of low back pain experiencing difficulty walking and 2 years of numbness in legs. On examination, there was dark brown pigmentation on the surface of all her teeth and horizontal brown lines on most of her teeth (figure 1A). She had spastic tetraparesis (strength at shoulder 4/5, legs 4/5) with generally brisk deep tendon jerks, extensor plantar responses and sensory loss below the T1 level. MR scan of the spine showed cervical spinal canal stenosis due to hypertrophy of posterior longitudinal ligament and ligamentum flavum, cervical cord hyperintensity (C3–C5) suggesting cervical myelopathy, and incidental cord compression by T2/T3 disc (figure 1B). X-ray of the pelvis showed calcification of the ilio-lumbar ligament, sacro-iliac and sacro-spinous ligaments and bony sclerosis (figure 1C). X-ray of forearm showed calcification of the interosseous membrane (figure 1D). Her urine fluoride concentration was 2.8 parts per million (normal <1). The fluoride concentration in the underground water that the family consumed was …
Contributors VA and ND collected the clinical and radiological data, wrote and revised the manuscript. VS analysed the figures and wrote figure legends. VKP conceived, wrote and revised the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests VA, ND, VS and VKP report no conflict of interest.
Patient consent for publication Obtained.
Provenance and peer review Not commissioned. Externally peer reviewed by Robin Lachmann, London, UK.
Data sharing statement All data relevant to the study are included in the article.