Tryptophan metabolism in alcoholic pellagra patients: measurements of urinary metabolites and histochemical studies of related muscle enzymes

Pellagra and alcoholism: a biochemical perspective

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: a review with emphasis on photosensitivity

Niacin has recently been demonstrated to lower blood pressure in hypertensive patients and to reduce cardiovascular events when combined with a statin. As a consequence, niacin has been elevated from being of historical interest as the treatment for pellagra, to being a compound with possible relevance to contemporary therapeutics. In spite of this, niacin deficiency leading to pellagra continues to be a health problem in some countries. Characterized by an exposed-site hyperpigmented dermatitis, pellagra is generally accepted to have been the first photosensitivity syndrome described. At its worst, pellagra manifests as one of the most striking examples of systemic photosensitivity. This is the only photosensitivity syndrome where death is included as a cardinal clinical feature (the often quoted four 'Ds': dermatitis, diarrhoea, dementia and death). However, the pathogenetic mechanism for the photosensitivity caused by niacin deficiency has yet to be determined. This review seeks to update the classification and phenotypic characterization of the various forms of niacin-deficient photosensitivity. Previous speculation about possible mechanisms for the pathogenesis of photosensitivity due to niacin deficiency is reviewed in the context of advances in the understanding of the photochemical basis of photosensitivity reactions. The review concludes by highlighting research required to advance the understanding of this photosensitivity syndrome.

The relationship of pellagra to corn and the low availability of niacin in cereals

The poorest inhabitants of an area generally eat the narrowest range of foods, and one staple (which serves as a cheap source of calories) dominates. In turn, the specific type of malnutrition seen in that area depends upon that predominant staple and how it is processed before consumption. Corn, used here in the sense of "Indian corn" or maize, was brought to Europe from America, and over the period 1750-1850 became the typical peasant's staple in many of the areas bordering the Mediterranean. By the end of that period, it had also come to be recognized that pellagra had become a serious, chronic disease in these same countries, flaring up each spring amongst the poorest people living on diets containing much corn and very little animal food (i.e., meat, eggs or dairy products) or wine and being generally in a state of wretchedness. Nothing of the sort was seen in areas where wheat and rice were the staple foods, even when they were highly milled. Most scientists agreed on this association with corn, though not on what was the true cause-and-effect relationship. Research in the present century has shown that pellagra is primarily due to a dietary deficiency of niacin. However, the niacin content of different foods did not tie in well with their pellagra-preventive value. But then it was discovered that a second nutrient, tryptophan, could act as precursor of the vitamin with approximately one sixtieth of the activity of the actual vitamin. The "niacin equivalent" values of foods (calculated from their content of both nutrients) show a much better correlation with their pellagra-preventive value. Thus, mature corn is lower in niacin content than are wheat and rice; also the mixed proteins of corn are lower in their tryptophan content. What is not explained by the calculation of "niacin equivalent" is the general freedom from pellagra of the peasants in Mexico and Central America, where corn has been the staple for millenia and where poverty, the consequent lack of animal foods in the diet, and general misery, have been fully equal to the conditions in Europe. It has been known for 40 years that analytical values for the niacin content of foods depended greatly on the method of extraction used, with the highest values being obtained after treatment with alkali. We have confirmed with rat growth assays that the niacin in corn, wheat and rice is only about one-third available to this species, even after ordinary cooking at neutral pH.(ABSTRACT TRUNCATED AT 400 WORDS)