The relation between vitamin D deficiency and fibromyalgia syndrome.

I have read Dr. Matthana’s intriguing article1 with its attractive title that linked fibromyalgia with vitamin D deficiency, as one recalls the overlap of the clinical features of fibromyalgia with those of osteomalacia (adult vitamin D deficiency disease). Dr. Matthana very well covered the recent literature on the subject, however, I have to question the accuracy of her diagnosis of fibromyalgia. Apart from fulfilling the American College of Rheumatology 1990 criteria for classification of fibromyalgia, some authorities in standard texts consider fibromyalgia as a diagnosis of exclusion,2 and admittedly, the author mentioned the exclusion of rheumatologic disorders. In an alternative expression, others impose a minimum investigation screen for some 5 clinically occult conditions that could contribute to some of the symptoms of fibromyalgia,3 in which the screen includes testing the serum alkaline phosphatase.3 The alkaline phosphatase is typically raised in osteomalacia with a reported elevation in 94% of biopsy-proved series of cases of osteomalacia.4 This test is totally missing in the text of Dr. Matthana’s article1 that means that Dr. Matthana did not exclude the likelihood of osteomalacia as a possibility, or comorbidity among her 100 female patients. The reported progressive improvement of the symptoms of some twothirds of her 61 vitamin D deficient patients conform best, if not only, with improvement of an underlying osteomalacic process as the cause of the symptoms. Dr. Matthana mentioned in the article that osteomalacia is quite a late manifestation of vitamin D deficiency.1 However, if we skip the phrase “at any age”, all features of the quotation are actually manifestations of osteomalacia or its associations.5 One wonders whether the prefix “osteo” (Greek osteon bone) has been interpreted as to necessitate radiologically demonstrable bone lesions to dare applying the term osteomalacia, but x-ray findings are only seen in the advanced disease.3 During the nineties of last century, while the United Nations Security Council blockade was imposed on Iraq, we saw and treated many osteomalacic, notably lactating women presenting with musculo-skeletal pain and tenderness with features of proximal muscle weakness, and mostly negative x-rays but positive biochemical tests, notably a raised serum alkaline phosphatase. The controversies on the nature of the association between vitamin D deficiency and fibromyalgia that Dr. Matthana discussed at length would have demanded more than one additional comment. The discussion brought her to conclude 2 possibilities. As her first choice stated: “. . . .vitamin D deficiency is misdiagnosed as fibromyalgia”,1 I refrained from further comments apart from adding that vitamin D deficiency disease in adults is the same as osteomalacia. The apparent misconception of the clinical features of osteomalacia may be ascribed to: 1) being overwhelmed by those of rickets of childhood, and 2) their further mix-up in the way of their presentation in some well-known texts. I have 3 examples of such books, notably all American, that the interested reader could consult.6-8