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Musculoskeletal pain in female asylum seekers and hypovitaminosis D3
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     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

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