Musculoskeletal pain in female asylum seekers and hypovitaminosis D3
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《英国医生杂志》
1 Medical Outpatient Clinic, University of Lausanne, Rue du Bugnon 44, 1011 Lausanne, Switzerland
Correspondence to: G de Torrenté de la Jara gabdetorrente@bluewin.ch
Introduction
Asylum seekers are at risk because of the possible high prevalence of hypovitaminosis D3 and difficulty in recognising the condition. The first diagnosis considered, in an often psychologically difficult context, is one suggestive either of somatoform disorder, as described in ICD-10 (international classification of diseases, 10th revision)9 or somatisation. Patients with psychological disorders may report multiple unexplained somatic symptoms,10 but pain due to hypovitaminosis D3 is well defined. Generally, this pain is symmetrical and starts in the lower back then spreads to the pelvis, upper legs, and ribs. It is felt mainly in the bones; not in the joints. Patients may also have proximal muscle weakness.
Symptoms may last for some time before diagnosis, causing important psychosocial repercussions in an already vulnerable population. This confirms the poor knowledge of hypovitaminosis D3 in doctors.5
With treatment, complete resolution is rapid—usually within three months. Doctors simultaneously treated patient 11 for a suspected venous insufficiency (varicose veins bilaterally and slight right foot oedema); the resolution of symptoms was due to either the combination of vitamin D and calcium or the treatment for venous insufficiency (support stockings, diosmin, and hesperidin tablets and heparin-allantoin-dexpanthenol gel) or both. The literature suggests that the resolution of symptoms associated with hypovitaminosis D3 typically occurs between three and six months: three months for symptoms due to the osteopathy5 and six months for the myopathy.7
The patients in our cases had low concentrations of 25-hydroxycholecalciferol. Even though the reference range for serum 25-hydroxycholecalciferol is difficult to determine, because it varies with season and geography, concentrations below 20 nmol/l indicate severe deficiency.11 12 Concentrations greater than 50 nmol/l prevent secondary hyperparathyroidism.13 Other authors have proposed that the cut-off concentration is 78 nmol/l,14 and for elderly people it may be greater than 100 nmol/l.15-17 Concentrations of at least 75 nmol/l are necessary to maintain cellular function.18 Achieving these concentrations requires the elimination of some risk factors, such as reduced exposure to sunlight (covering arms and legs while outdoors, winter season, and housebound status) and a strict vegetarian diet, which are the most reliable predictors of hypovitaminosis D3.19-21 Nevertheless, large educational campaigns within an Asian community resulted in an improvement in vitamin D deficiency among only the children.22 Routine vitamin D supplementation seems to be beneficial for populations at risk.8 12 Various authors recommend a daily intake of 800-1000 IU (50-62.5 nmol; 20-25 μg) for benefits in health.12 17
A recent study found that 28% of patients (immigrants and non-immigrants) presenting with persistent non-specific musculoskeletal pain in a community health centre in Minnesota had severe vitamin D deficiency, emphasising the importance of this disorder.23 Hypovitaminosis D3 in female asylum seekers may remain undiagnosed with a prolonged duration of chronic symptoms and the associated pitfall of potential misdiagnosis of the symptoms as somatisation. Treatment is beneficial, with a rapid resolution of symptoms. Doctors should be aware of the importance of the disease and the impact of rapid diagnosis and treatment. Future research should consider routine supplementation in this population.
We thank W Ghali (University of Calgary, AB, Canada) for his comments and corrections on the revised manuscript and M Spasojevic and FH for the translations.
Contributors: GdeTdelaJ initiated the study, collected the data in the patients' files, wrote the text, and saw patients for their written consent. AP gave authorisation for the study to be done in the outpatient clinic and supervised it. BF initiated and supervised the study. BF is guarantor.
Funding: None.
Competing interests: None declared.
Ethical approval: Not needed.
Female asylum seekers with persistent non-specific musculoskeletal pain should be screened for hypovitaminosis D3
References
Ford JA, Colhoun EM, McIntosh WB, Dunnigan MG. Rickets and osteomalacia in the Glasgow Pakistani community, 1961-71. BMJ 1972;2: 677-80.
Holmes AM, Enoch BA, Taylor JL, Jones ME. Occult rickets and osteomalacia among the Asian immigrant population. Q J Med 1973;165: 125-49.
Preece MA, McIntosh WB, Tomlinson S, Ford JA, Dunnigan MG, O'Riordan JL. Vitamin-D deficiency among Asian immigrants to Britain. Lancet 1973;i: 907-10.
Stamp TC, Walker PG, Perry W, Jenkins MV. Nutritional osteomalacia and late rickets in Greater London, 1974-1979: clinical and metabolic studies in 45 patients. Clin Endocrinol Metab 1980;9: 81-105.
Nellen JFJB, Smulders YM, Frissen PHJ, Slaats EH, Silberbusch J. Hypovitaminosis D in immigrant women: slow to be diagnosed. BMJ 1996;312: 570-2.
Serhan E, Newton P, Ali HA, Walford S, Singh BM. Prevalence of hypovitaminosis D in Indo-Asian patients attending a rheumatology clinic. Bone 1999;25: 609-11.
Glerup H, Mikkelsen K, Poulsen L, Hass E, Overbeck S, Andersen H, et al. Hypovitaminosis D myopathy without biochemical signs of osteomalacic bone involvement. Calcif Tissue Int 2000;66: 419-24.
Utiger RD. The need for more vitamin D. N Engl J Med 1998;338: 828-9.
World Health Organization. The ICD-10 classification of mental and behavioral disorders: clinical descriptions and diagnostic guidelines. Geneva: WHO, 1992.
Simon GE, VonKorff M, Piccinelli M, Fullerton C, Ormel J. An international study of the relation between somatic symptoms and depression. N Engl J Med 1999;341: 1329-35.
McKenna MJ. Differences in vitamin D status between countries in young adults and the elderly. Am J Med 1992;93: 69-77.
Compston JE. Vitamin D deficiency: time for action. BMJ 1998;317: 1446-7.
Malabanan A, Veronikis IE, Holick MF. Redefining vitamin D insufficiency. Lancet 1998;351: 805-6.
Chapuy MC, Preziosi P, Maamer M, Arnaud S, Galan P, Hercberg S, et al. Prevalence of vitamin D insufficiency in an adult normal population. Osteoporos Int 1997;7: 439-43.
Chapuy MC, Arlot ME, Duboeuf F, Brun J, Crouzet B, Arnaud S, et al. Vitamin D3 and calcium to prevent hip fractures in elderly women. N Engl J Med 1992;327: 1637-42.
Dawson-Hughes B, Harris SS, Krall EA, Dallal GE. Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. N Engl J Med 1997;337: 670-6.
Vieth R. Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety. Am J Clin Nutr 1999;69: 842-56.
Holick MF. Vitamin D: the underappreciated D-lightful hormone that is important for skeletal and cellular health. Curr Opinion Endocrinol Diabetes 2002;9: 87-98.
Thomas MK, Lloyd-Jones DM, Thadhani RI, Shaw AC, Deraska DJ, Kitch BT, et al. Hypovitaminosis D in medical inpatients. N Engl J Med 1998;338: 777-83.
Finch PJ, Ang L, Eastwood JB, Maxwell JD. Clinical and histological spectrum of osteomalacia among Asians in South London. Q J Med 1992;83: 439-48.
Smith R. Asian rickets and osteomalacia. Q J Med 1990;6: 899-901.
Stephens WP, Klimiuk PS, Warrington S, Taylor JL, Berry JL, Mawer EB. Observations on the natural history of vitamin D deficiency amongst Asian immigrants. Q J Med 1982;202: 171-88.
Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc 2003;78: 1463-70.(Gabrielle de Torrenté de )
Correspondence to: G de Torrenté de la Jara gabdetorrente@bluewin.ch
Introduction
Asylum seekers are at risk because of the possible high prevalence of hypovitaminosis D3 and difficulty in recognising the condition. The first diagnosis considered, in an often psychologically difficult context, is one suggestive either of somatoform disorder, as described in ICD-10 (international classification of diseases, 10th revision)9 or somatisation. Patients with psychological disorders may report multiple unexplained somatic symptoms,10 but pain due to hypovitaminosis D3 is well defined. Generally, this pain is symmetrical and starts in the lower back then spreads to the pelvis, upper legs, and ribs. It is felt mainly in the bones; not in the joints. Patients may also have proximal muscle weakness.
Symptoms may last for some time before diagnosis, causing important psychosocial repercussions in an already vulnerable population. This confirms the poor knowledge of hypovitaminosis D3 in doctors.5
With treatment, complete resolution is rapid—usually within three months. Doctors simultaneously treated patient 11 for a suspected venous insufficiency (varicose veins bilaterally and slight right foot oedema); the resolution of symptoms was due to either the combination of vitamin D and calcium or the treatment for venous insufficiency (support stockings, diosmin, and hesperidin tablets and heparin-allantoin-dexpanthenol gel) or both. The literature suggests that the resolution of symptoms associated with hypovitaminosis D3 typically occurs between three and six months: three months for symptoms due to the osteopathy5 and six months for the myopathy.7
The patients in our cases had low concentrations of 25-hydroxycholecalciferol. Even though the reference range for serum 25-hydroxycholecalciferol is difficult to determine, because it varies with season and geography, concentrations below 20 nmol/l indicate severe deficiency.11 12 Concentrations greater than 50 nmol/l prevent secondary hyperparathyroidism.13 Other authors have proposed that the cut-off concentration is 78 nmol/l,14 and for elderly people it may be greater than 100 nmol/l.15-17 Concentrations of at least 75 nmol/l are necessary to maintain cellular function.18 Achieving these concentrations requires the elimination of some risk factors, such as reduced exposure to sunlight (covering arms and legs while outdoors, winter season, and housebound status) and a strict vegetarian diet, which are the most reliable predictors of hypovitaminosis D3.19-21 Nevertheless, large educational campaigns within an Asian community resulted in an improvement in vitamin D deficiency among only the children.22 Routine vitamin D supplementation seems to be beneficial for populations at risk.8 12 Various authors recommend a daily intake of 800-1000 IU (50-62.5 nmol; 20-25 μg) for benefits in health.12 17
A recent study found that 28% of patients (immigrants and non-immigrants) presenting with persistent non-specific musculoskeletal pain in a community health centre in Minnesota had severe vitamin D deficiency, emphasising the importance of this disorder.23 Hypovitaminosis D3 in female asylum seekers may remain undiagnosed with a prolonged duration of chronic symptoms and the associated pitfall of potential misdiagnosis of the symptoms as somatisation. Treatment is beneficial, with a rapid resolution of symptoms. Doctors should be aware of the importance of the disease and the impact of rapid diagnosis and treatment. Future research should consider routine supplementation in this population.
We thank W Ghali (University of Calgary, AB, Canada) for his comments and corrections on the revised manuscript and M Spasojevic and FH for the translations.
Contributors: GdeTdelaJ initiated the study, collected the data in the patients' files, wrote the text, and saw patients for their written consent. AP gave authorisation for the study to be done in the outpatient clinic and supervised it. BF initiated and supervised the study. BF is guarantor.
Funding: None.
Competing interests: None declared.
Ethical approval: Not needed.
Female asylum seekers with persistent non-specific musculoskeletal pain should be screened for hypovitaminosis D3
References
Ford JA, Colhoun EM, McIntosh WB, Dunnigan MG. Rickets and osteomalacia in the Glasgow Pakistani community, 1961-71. BMJ 1972;2: 677-80.
Holmes AM, Enoch BA, Taylor JL, Jones ME. Occult rickets and osteomalacia among the Asian immigrant population. Q J Med 1973;165: 125-49.
Preece MA, McIntosh WB, Tomlinson S, Ford JA, Dunnigan MG, O'Riordan JL. Vitamin-D deficiency among Asian immigrants to Britain. Lancet 1973;i: 907-10.
Stamp TC, Walker PG, Perry W, Jenkins MV. Nutritional osteomalacia and late rickets in Greater London, 1974-1979: clinical and metabolic studies in 45 patients. Clin Endocrinol Metab 1980;9: 81-105.
Nellen JFJB, Smulders YM, Frissen PHJ, Slaats EH, Silberbusch J. Hypovitaminosis D in immigrant women: slow to be diagnosed. BMJ 1996;312: 570-2.
Serhan E, Newton P, Ali HA, Walford S, Singh BM. Prevalence of hypovitaminosis D in Indo-Asian patients attending a rheumatology clinic. Bone 1999;25: 609-11.
Glerup H, Mikkelsen K, Poulsen L, Hass E, Overbeck S, Andersen H, et al. Hypovitaminosis D myopathy without biochemical signs of osteomalacic bone involvement. Calcif Tissue Int 2000;66: 419-24.
Utiger RD. The need for more vitamin D. N Engl J Med 1998;338: 828-9.
World Health Organization. The ICD-10 classification of mental and behavioral disorders: clinical descriptions and diagnostic guidelines. Geneva: WHO, 1992.
Simon GE, VonKorff M, Piccinelli M, Fullerton C, Ormel J. An international study of the relation between somatic symptoms and depression. N Engl J Med 1999;341: 1329-35.
McKenna MJ. Differences in vitamin D status between countries in young adults and the elderly. Am J Med 1992;93: 69-77.
Compston JE. Vitamin D deficiency: time for action. BMJ 1998;317: 1446-7.
Malabanan A, Veronikis IE, Holick MF. Redefining vitamin D insufficiency. Lancet 1998;351: 805-6.
Chapuy MC, Preziosi P, Maamer M, Arnaud S, Galan P, Hercberg S, et al. Prevalence of vitamin D insufficiency in an adult normal population. Osteoporos Int 1997;7: 439-43.
Chapuy MC, Arlot ME, Duboeuf F, Brun J, Crouzet B, Arnaud S, et al. Vitamin D3 and calcium to prevent hip fractures in elderly women. N Engl J Med 1992;327: 1637-42.
Dawson-Hughes B, Harris SS, Krall EA, Dallal GE. Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. N Engl J Med 1997;337: 670-6.
Vieth R. Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety. Am J Clin Nutr 1999;69: 842-56.
Holick MF. Vitamin D: the underappreciated D-lightful hormone that is important for skeletal and cellular health. Curr Opinion Endocrinol Diabetes 2002;9: 87-98.
Thomas MK, Lloyd-Jones DM, Thadhani RI, Shaw AC, Deraska DJ, Kitch BT, et al. Hypovitaminosis D in medical inpatients. N Engl J Med 1998;338: 777-83.
Finch PJ, Ang L, Eastwood JB, Maxwell JD. Clinical and histological spectrum of osteomalacia among Asians in South London. Q J Med 1992;83: 439-48.
Smith R. Asian rickets and osteomalacia. Q J Med 1990;6: 899-901.
Stephens WP, Klimiuk PS, Warrington S, Taylor JL, Berry JL, Mawer EB. Observations on the natural history of vitamin D deficiency amongst Asian immigrants. Q J Med 1982;202: 171-88.
Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain. Mayo Clin Proc 2003;78: 1463-70.(Gabrielle de Torrenté de )