Pellagra: Interesting Alert-NIH

WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Despite the treatable dementia and psychosis, pellagra is often under-diagnosed, especially in developed countries and alcoholic patients. Pellagra should be routinely suspected in alcoholic patients because the response to appropriate treatment is typically dramatic.


Alcoholic Pellagra as a Cause of Altered Mental Status in the Emergency Department ~ Source-NIH

BACKGROUND:

Pellagra, which is caused by a deficiency of niacin and tryptophan, the precursor of niacin, is a rare disease in developed countries where alcoholism is a major risk factor due to malnutrition and lack of B vitamins. Although pellagra involves treatable dementia and psychosis, it is often underdiagnosed, especially in developed countries.

CASE REPORT:

In Japan, a 37-year-old man presented to the emergency department with altered mental status and seizures. Wernicke encephalopathy and alcohol withdrawal were suspected. The patient was treated with multivitamins, which did not include nicotinic acid amide, and oral diazepam. Despite medical treatment, his cognitive impairment progressively worsened, and eventually, pellagra was suspected. His response to treatment with nicotinic acid amide was substantial, and he was discharged without any long-term sequelae. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Despite the treatable dementia and psychosis, pellagra is often underdiagnosed, especially in developed countries and alcoholic patients. Pellagra should be routinely suspected in alcoholic patients because the response to appropriate treatment is typically dramatic.

Pellagra and Alcoholism

In many cases, diagnosing pellagra involves seeing if your symptoms respond to niacin supplements. ~Healthline

How is it treated?

Primary pellagra is treated with dietary changes and a niacin or nicotinamide supplement. It may also need to be given intravenously. Nicotinamide is another form of vitamin B-3. With early treatment, many people make a full recovery and start feeling better within a few days of starting treatment. Skin improvement may take several months. However, if left untreated, primary pellagra usually causes death after four or five years.

A Biochemical Perspective ~ Source NIH

Historical and clinical aspects of pellagra and its relationship to alcoholism are reviewed from a biochemical perspective. Pellagra is caused by deficiency of niacin (nicotinic acid) and/or its tryptophan (Trp) precursor and is compounded by B vitamin deficiencies. Existence on maize or sorghum diets and loss of or failure to isolate niacin from them led to pellagra incidence in India, South Africa, Southern Europe in the 18th century and the USA following the civil war.

Pellagra is also induced by drugs inhibiting the conversion of Trp to niacin and by conditions of gastrointestinal dysfunction. Skin photosensitivity in pellagra may be due to decreased synthesis of the Trp metabolite picolinic acid → zinc deficiency → decreased skin levels of the histidine metabolite urocanic acid and possibly also increased levels of the haem precursor 5-aminolaevulinic acid (5-ALA) and photo-reactive porphyrins.

Depression in pellagra may be due to a serotonin deficiency caused by decreased Trp availability to the brain. Anxiety and other neurological disturbances may be caused by 5-ALA and the Trp metabolite kynurenic acid.

Pellagra symptoms are resolved by niacin, but aggravated mainly by vitamin B6. Alcohol dependence can induce or aggravate pellagra by inducing malnutrition, gastrointestinal disturbances and B vitamin deficiencies, inhibiting the conversion of Trp to niacin and promoting the accumulation of 5-ALA and porphyrins. Alcoholic pellagra encephalopathy should be managed with niacin, other B vitamins and adequate protein nutrition. Future studies should explore the potential role of 5-ALA and also KA in the skin and neurological disturbances in pellagra.


Pellagra encephalopathy following B-complex vitamin treatment without niacin. ~ Source NIH

Pellagra is caused by nicotinic acid deficiency; it is rarely encountered in developed countries, and it is mainly related to poverty and malnutrition, as well as with chronic alcoholism. We report the case of an alcoholic patient who was diagnosed with pellagra and administered B-complex vitamin tablets that did not contain niacin. A few weeks later, the patient developed nervousness, irritability, insomnia and, consequently, delusional ideas and hallucinations, for which he had to be hospitalized. After his admission, the patient manifested loss of consciousness and myoclonus. All of his symptoms (cutaneous, neurological, and psychiatric) resolved fully with treatment with niacin in combination with other B-complex vitamins. All undiagnosed encephalopathies in alcoholic patients should be treated with multiple vitamin therapy, including nicotinic acid.


Pellagra: rekindling of an old flame. ~ Source

Pellagra is a disease largely associated with alcohol abuse, poverty, and malnutrition and is very common in developing countries. However, in the wake of “slimmer is better” fads and the ever-growing population of patients infected with human immunodeficiency virus, it may be on the surge in the United States. This vitamin deficiency disorder, though easy to diagnose and treat, can be easily missed and requires a high index of suspicion. We describe a case involving a patient who presented with the classic triad of “diarrhea, dermatitis, and dementia” and was promptly diagnosed and appropriately treated.


Treating secondary pellagra usually focuses on treating the underlying cause. However, some cases of secondary pellagra also respond well to taking niacin or nicotinamide either orally or intravenously.

While recovering from either primary or secondary pellagra, it’s important to keep any rashes moisturized and protected with sunscreen.

Pellagra is a serious condition that’s caused by low levels of niacin, due to either malnutrition or an absorption problem. If left untreated, it can cause death.

While primary pellagra responds well to niacin supplementation, secondary pellagra can be harder to treat, depending on the underlying cause.