Chronic tea ingestion causing bone pain and “rugger-jersey spine”

March 28, 2013, 1:58 pm

Rugger-jersey spine


Skeletal Fluorosis Due to Excessive Tea Drinking. Kakumanu N, Rao SD. N Engl J Med 2013 Mar 21;368:1140.

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“Sick of tea? That’s like being sick of breathing!”
Uncle Iroh

This very interesting, very short case report describes a 47-year-old woman who presented with a 5-year history of pain in the lower back and extremities.  Work-up revealed an elevated serum fluoride level.

Radiographs (reproduced in the report) showed calcification of the interosseous membranes of the forearms and increased density of the upper and lower parts of the vertebrae (so-called “rugger-jersey spine”). These findings are characteristic of skeletal fluorosis.

Dietary history determined that the patient had been ingesting a pitcher of tea each day for 17 years. Each pitcher was made with 100-150 (!) teabags. (It’s a wonder she didn’t develop caffeine toxicity.)

Camellia sinensis, the plant used to make many teas, contains large amounts of F ions, which are structurally similar to hydroxide (OH). Over time, incorporation of fluoride ions into the bone matrix produces a denser but weaker material that is easily deformed or fractured. Secondary hyperparathyroidism often results.

Characteristic x-ray findings include osteosclerosis, soft tissue calcification, kyphosis,  and the “rugger-jersey spine“. Suspected chronic fluorosis can be confirmed by a bone biopsy, or analysis of fingernail and toenail clippings.

Key take-home lesson: in a patient with unexplained chronic bone pain and x-ray changes suggestive of metabolic bone disease, consider a diagnosis of skeletal fluorosis.

Several similar cases (for example, this one) have been published previously.

[X-ray of “rugger-jersy spine” from]



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