The Egyptian Journal of Neurology, Psychiatry and Neurosurgery

: 2016  |  Volume : 53  |  Issue : 3  |  Page : 174--178

Effects of vitamin D deficiency on the relapse, severity, and disability of multiple sclerosis

Ahmed Esmael1, Mohammed El-Sherif1, Ayman A Elazzouny2,  
1 Department of Neurology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
2 Department of Neurology, Misr University for Sciences and Technology, Giza, Egypt

Correspondence Address:
Mohammed El-Sherif
Department of Neurology, Faculty of Medicine, Mansoura University, Mansoura 35516, Dakahlia


Background Multiple sclerosis (MS) is a long-standing inflammatory disease of the white matter and affects more than two million people worldwide. Upcoming evidence proposed that 25-hydroxy-vitamin D3 (25HVD3) deficiency could be one of the most crucial environmental elements for the pathogenesis of MS. Objective The aim of this study was to compare 25HVD3 levels in MS patients and controls and to detect the association with relapse, severity, and disability in MS patients. Patients and methods Mansoura Neurology Department data sheet was collected and all patients were assessed using the Expanded Disability Status Scale (EDSS) at the onset. 25HVD3 levels in the blood were evaluated for all patients and controls using the chemiluminescent immunoassay test. Results A total of 50 MS patients were included in this work and matched with 25 controls. There was a statistically significantly lower mean serum 25HVD3 level in MS patients in comparison with the controls (20.5 ± 16.8 and 42.9 ± 17.9 ng/ml, respectively; P = 0.002). In addition, there was a statistically significantly lower level of 25HVD3 (18.4 ± 17.7) in severe cases of MS (EDSS ≥ 6; P < 0.05) with certain significant clinical features such as older age (P < 0.001) and longer disease duration (P < 0.001). The incidence of 25HVD3 deficiency (<20 ng/ml) in MS patients was 60%. Conclusion Our results showed that there is an inverse correlation between 25HVD3 level and EDSS score. In addition, lower 25HVD3 levels are associated with increased relapse risk in MS.

How to cite this article:
Esmael A, El-Sherif M, Elazzouny AA. Effects of vitamin D deficiency on the relapse, severity, and disability of multiple sclerosis.Egypt J Neurol Psychiatry Neurosurg 2016;53:174-178

How to cite this URL:
Esmael A, El-Sherif M, Elazzouny AA. Effects of vitamin D deficiency on the relapse, severity, and disability of multiple sclerosis. Egypt J Neurol Psychiatry Neurosurg [serial online] 2016 [cited 2023 Dec 11 ];53:174-178
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Multiple sclerosis (MS) is a long-standing, demyelinating with immune-mediated basis, and disabling central nervous system disease affecting predisposed patients with assertive genetic susceptibility alongside specific environmental circumstances exposure. The highest incidence is in those between 20 and 30 years of age. The female population has two times greater risk for MS compared with the male population [1].

Fundamentally, there is a negative association between the decrease in the sunlight exposure [mainly, decreased ultraviolet radiation exposure and subsequently decreased 25-hydroxy-vitamin D3 (25HVD3) level] and occurrence of MS. Thus, MS prevalence differs with geographic coordinate system (latitude) and it is high in districts after the 40th parallels (both south and north) [2],[3],[4].

There are many observations – for example, during fetal life, 25HVD3 assists in the formation of the immunological tolerance, leading to the removal of self-reactive lymphocytes [5]. Moreover, 25HVD3 receptors were discovered in the rat brain and spinal cord regions [6]. Moreover, the intake of 25HVD3 by the mother during pregnancy is associated with a subsequent lower risk for MS of the child [7].

As regards the Middle East, there is little evidence in the literature about the relationship between MS disease and serum 25HVD3 levels. Hashem et al. [8] observed that the prevalence of MS in Egypt was in the range 1.41–14.1% per 1000 other neurological diseases. Moreover, El-Ghoneimy et al. [9] stated that the prevalence of 25HVD3 deficiency among MS patients was 86.7%.


The aim of this study was to compare 25HVD3 levels in MS patients and healthy controls, and to detect the association with relapse, severity, and disability in MS patients.

 Patients and methods

Fifty patients with MS were included in this study and admitted in the Neurology Department of Mansoura University Hospital (Mansoura, Egypt). Inclusion criteria were as follows: definite MS according to Poser et al. [10] criteria, or brain MRI-supported definite MS according to Paty and Li [11] criteria. Patients were diagnosed as having relapsing remitting multiple sclerosis (RRMS), primary progressive multiple sclerosis (PPMS), or secondary progressive multiple sclerosis (SPMS) according to the classification of Lublin and Reingold [12] and with normal routine laboratory investigations (complete blood count, blood glucose level, and renal and liver functions). Patients with any associated medical or neurological diseases were excluded from this study. As regards the control group, 25 healthy individuals were selected as the control group and were matched for age and sex. The control group was free of neurological or chronic disease, and did not have any family member with MS. They underwent MRI of the brain to exclude white matter lesions. The study protocol was approved by the Local Ethical Committee at the hospital. All enrolled patients had signed written fully informed consent to participate in the study.

Patients were evaluated clinically, especially for age of onset, duration of illness, precipitating factors, whether active, course of MS (either relapsing or progressive), first signs and symptoms, family history of MS, other diseases, current use of corticosteroids, and rehabilitation treatments. The Expanded Disability Status Scale (EDSS) is a functional scale to determine the degree of disability and monitor disease progression. The EDSS includes eight functional systems, visual, sensory, cerebellar, brainstem, pyramidal, bowel and bladder, mental, and other functions. The scores range from 0 (neurologically free) to 10 (death). Patients were classified according to the severity of MS as follows: mild (0–3 EDSS), moderate (3.5–5.5 EDSS), and severe (≥6 EDSS) [13]. Blood samples were obtained from patients and controls after overnight fasting. Blood samples were examined using the chemiluminescent immunoassay test (DiaSorin Liaison Kit; DiaSorin S.P.A, Saluggia, Italy) for 25HVD3 levels, all in the same laboratory. The 25HVD3 levels were categorized into low (<20 ng/ml = 50 nmol/l), medium (20–40 ng/ml), and high (>40 ng/ml) levels [14].

Statistical analysis

SPSS, version 15, 2006 for Windows statistical package (SPSS Inc., Chicago, Illinois, USA) was used for statistical analysis. Collected data were presented as mean ± SD, ranges, numbers, and ratios. Pearson’s χ2-test was used for comparisons. The result was considered statistically significant if P value was less than 0.05. The Mann–Whitney U-test was used to compare 25HVD3 levels of MS cases and healthy controls. Pearson’s correlation analysis was performed to evaluate the correlation of 25HVD3 level with severity of MS. The relationships between serum 25HVD3 concentrations for the incidence of relapse and severity of MS were assessed using Poisson regression models with the geometric mean individual serum levels.


A total of 50 MS patients were included in this work and matched with 25 healthy individuals as controls. The mean age was 35.1 ± 9.1 (range: 19–55) years for patients and 34.8 ± 8.9 (range: 18–56) years for controls (P = 0.920). The most common age group of MS patients was from 20 to 40 (74% of patients) years. RRMS was the most common type, constituting 72% of patients, followed by SPMS (22%) and PPMS (6%). Most of the controls and MS patients were female (female to male ratio: 2.5: 1). The mean EDSS score of MS patients was 2.5 ± 4.5 and the mean duration of disease was 6.3 ± 0.2 years. The mean relapse number in the previous 2 years was 2.4 ± 1.6. The mean serum 25HVD3 levels was 20.5 ± 16.8 ng/ml in patients with MS versus 42.9 ± 17.9 ng/ml in controls with high statistical significance (P = 0.002) [Table 1] and [Table 2].{Table 1}{Table 2}

Comparison of subgroups of MS patient’s severity showed a statistically significantly lower serum level of 25HVD3 (18.4 ± 17.7) in severe cases of MS (EDSS≥6) (P < 0.05). Moreover, there was a significant association of older age (P < 0.001) and longer disease duration (P < 0.001) with severe cases of MS. Moreover, female sex (32; 78%) was significantly associated with mild-to-moderate severity of MS (EDSS between 0 and 5.5; P = 0.042) [Table 3].{Table 3}

As regards the association between serum 25HVD3 concentrations and severity of MS, the severity of MS was significantly increased in the group with low serum 25HVD3 concentrations (<20 ng/ml) compared with the group with high serum concentration medium (>40 ng/ml). Rate ratios for the low and the medium group were 2.0 and 1.5, respectively (P value for the lower level group was 0.007). The incidence of 25HVD3 deficiency (<20 ng/ml) in MS patients was 60% [Table 4].{Table 4}

There was a strong significant inverse linear relationship between the relapse incidence in the previous 2 years and the 25HVD3 level (P < 0.005), indicating that vitamin D level influences the relapse of MS [Table 5].{Table 5}

As shown in [Figure 1], an inverse correlation was observed between 25HVD3 level and EDSS score (P < 0.001). [Figure 2] shows the comparison of the level of 25HVD3 in MS patients with different severities of disease showing a significant increase in the severity of MS with lower levels of 25HVD3 (P < 0.05).{Figure 1}{Figure 2}


Previous studies found that serum 25HVD3 levels of less than 20 ng/ml (50 nmol/l) indicate vitamin D deficiency. However, the levels below 30 ng/ml indicate insufficiency, and levels between 30 and 60 ng/ml (75 and 150 nmol/l) represent normal values [15]. This is in agreement with the present study results, as the normal value in the control group was 42.9 ± 17.9 ng/ml, whereas the MS group showed decreased levels (20.5 ± 16.8 ng/ml).

As regards the relation between MS and 25HVD3, there were many observations. Munger et al. [16] stated that the high circulating levels of 25HVD3 were associated with a lower risk for MS (every 50 nmol/l increase in serum 25HVD3 led to a 41% decrease in MS risk). Moreover, Mirzaei et al. [7] reported that MS risk was lower among women born to mothers with high milk or vitamin D intake during pregnancy. Furthermore, Mowry et al. [17] found that each 10 ng/ml increase in 25HVD3 level was associated with a 15% lower risk for a new T2 lesion and a 32% lower risk for a gadolinium-enhancing lesion. Each 10 ng/ml increase in vitamin D level was associated with lower subsequent disability, suggesting that higher vitamin D levels were associated with lower relapse risk [17].

Although the link between vitamin D supplementation and decreased risk for MS has been widely assumed, present vitamin D repletion therapies have not yet shown a significant effect on the progress of MS. Kampman et al. [18] found that supplementation with 20 000 IU vitamin D weekly did not result in beneficial effects on MS-related outcomes.

The course of MS disease in Egyptian studies was found to be 65, 12, and 9% in RRMS, SPMS, and PPMS, respectively [19]. However, in the present study it was 72, 22, and 6%, respectively.

El-Ghoneimy et al. [9] stated that the prevalence of 25HVD3 deficiency (<20 ng/ml) among MS patients was 86.7%. However, in the study by Ozgocmen et al. [20], Weinstock-Guttman et al. [21], and Nieves et al. [22], the prevalence was 61, 37.5, and 23%, respectively. In the present study, it was 60%. The difference in the prevalence rates may be due to many limitations of previous studies or different sample sizes and these factors need more Egyptian research studies to clarify it.

In the present study, lower 25HVD3 levels are significantly associated with a higher exacerbation risk in MS patient of about two times higher than that in the category of high levels, and this result is similar to the finding of Runia et al. [14]. Simpson et al. [23] concluded that exacerbation risk was significantly decreased with higher vitamin D levels.

Our results reported a negative correlation between serum 25HVD3 levels and EDSS and severity of MS. In the study by van der Mei et al. [24] on 136 MS patients and 272 community controls in Tasmania, Australia, cases of lower vitamin D level had higher disability (EDSS > 3). The similar significant inverse correlation was reported by Smolders et al. [25] in their study on 267 patients. This is not in accordance with the findings of Gelfand et al. [26], who stated that there was no apparent association between 25HVD3 and MS disease severity, and they predisposed this to the sample size limitations, smaller effect sizes in darker pigmented populations, or the use of the MS severity scale, and not using the relapse rate, as a marker of disease severity [23],[27].

Bäärnhielm et al. [28] reported that MS patients who had 25HVD3 levels less than 20 ng/ml (50 nmol/l) had an increased risk for MS. This is in agreement with the present study as severe MS cases (EDSS ≥ 6) showed lower 25HVD3 levels (<20 ng/ml) with marked relapse severity.


Our results showed that there is an inverse correlation between the 25HVD3 level and EDSS score; thus, the severity of MS increases with lower levels of 25HVD3. Lower vitamin D levels are associated with increased relapse risk in MS.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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