Abstract 10: Melorheosteosis-fluorosis conundrum in a patient of hypoparathyroidism

Background: Osteosclerosis is a condition characterized by high bone mineral density associated with disorders such as hypoparathyroidism, renal osteodystrophy, fluorosis and osteopetrosis. Hypoparathyroidism and fluorosis are two of the most common diseases causing sclerotic bone disease. Fluorosis also causes secondary hyperparathyroidism and has been implicated in renal dysfunction. Co-Occurrence of these disorders is both rare and confusing. Case Summary: 42-year-old male, previously diagnosed case of hypoparathyroidism presented with, fixed flexion deformity of the spine and limbs, episode of seizure, recurrent carpopedal spasms and low back ache. On examination there was positive Chvostek's and trousseau signs, proximal muscle weakness and restriction of movement at both hip and spine, dental examination revealed mottling of without any discernable pitting. On investigation serum calcium was low (5.92 mg/dl), serum phosphorus was high (7.82 mg/dl). Serum PTH and vitamin D levels were 2.9 pg/ml and 26.8 ng/ml respectively. Xray was suggestive of osteopetrosis, DXA SCAN-Left neck femur: +3.8, Lumbar spine: +5.9. On further workup, patients drinking water fluoride content was measured and was found to be 12 ppm over 10 times the recommended WHO limit. The candle wax appearance especially in the tibia also posed melorheosteosis as a potential differential diagnosis but the fact that the patient hailed from the fluoride belt of Rajasthan and other features along with raised fluoride led us to the diagnosis of Hypoparathyroidism with fluorosis and the patient was managed on oral calcium and calcitriol. Conclusion: Hypoparathyroidism together with fluorosis is a rare entity and timely diagnosis can prevent morbidity and improve the quality of life.