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Munagama CL, Silva S. Atypical presentation of pellagra with black urine: A clinical conundrum. SAGE Open Med Case Rep 2024; 12:2050313X241266558. [PMID: 39071187 PMCID: PMC11282565 DOI: 10.1177/2050313x241266558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/10/2024] [Indexed: 07/30/2024] Open
Abstract
Niacin (Vitamin B3) plays a crucial role as a vitamin in cellular energy production, metabolism, and DNA repair. A severe deficiency of this vitamin can lead to pellagra, which is characterized by dermatitis, dementia, diarrhoea and eventually death if untreated. A 68-year-old woman with a poor socioeconomic background presented with photosensitive dermatitis, fever, abdominal pain, and diarrhoea. Her urine changed to port wine colour following sun exposure. Porphyria cutanea tarda was excluded in the absence of demonstrable urine spectrophotometry. A diagnosis of pellagra was made, and timely management led to a complete cure. Proper diagnosis and effective treatment of pellagra are imperative as this condition can be life-threatening if left untreated.
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Affiliation(s)
| | - Shehan Silva
- University Medical Unit, Colombo South Teaching Hospital, Kalubowila, Sri Lanka
- Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka
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Barrah S, Jebali H, Kheder R, Krid M, Smaoui W, Beji S, Hmida FB, Fatma LB, Rais L, Zouaghi MK. Pellagra Disease in a Hemodialysis Patient. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2021; 31:874-876. [PMID: 32801252 DOI: 10.4103/1319-2442.292325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pellagra usually results from niacin deficiency and presents with the classic triad of dermatitis, diarrhea, and dementia. It is most commonly associated with malnutrition and poverty. We report a case of pellagra in a hemodialysis (HD) patient with breast neoplasia, aged 68-years, female, on HD unit for seven years. Her original nephropathy was indeterminate. The patient was followed up for homozygous beta-thalassemia and breast neoplasia with hepatic metastases on chemotherapy. The body mass index of the patient was 18.5 kg/m2. Physical examination showed a thickening of the epidermis with a scaly surface, pigmented, and atrophied areas. We noted neuropsychiatric signs (apathy, irritability, anorexia, and depression) and digestive symptomatology (diarrhea). The laboratory tests revealed hypoproteinemia at 55 g/L, hypoalbuminemia at 21 g/L, and hypocholesterolemia at 0.8 g/L. The diagnosis of pellagra disease was made. Vitamin and protein supplementation was initiated, but the patient committed suicide by puncture of her arteriovenous fistula, causing hemorrhagic shock. Pellagra is usually reported to be associated with malnutrition, chronic alcoholism, and some chemotherapeutic agents. In our patient, pellagra was caused by malnutrition and co-morbidities. Pellagra disease requires multidisciplinary care and can be frequently seen in HD patients due to the associated malnutrition.
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Affiliation(s)
- Sana Barrah
- Department of Nephrology, Dialysis and Transplantation, La Rabta Hospital, Tunis, Tunisia
| | - Hela Jebali
- Department of Nephrology, Dialysis and Transplantation, La Rabta Hospital, Tunis, Tunisia
| | - Rania Kheder
- Department of Nephrology, Dialysis and Transplantation, La Rabta Hospital, Tunis, Tunisia
| | - Madiha Krid
- Department of Nephrology, Dialysis and Transplantation, La Rabta Hospital, Tunis, Tunisia
| | - Wided Smaoui
- Department of Nephrology, Dialysis and Transplantation, La Rabta Hospital, Tunis, Tunisia
| | - Soumaya Beji
- Department of Nephrology, Dialysis and Transplantation, La Rabta Hospital, Tunis, Tunisia
| | - Fathi Ben Hmida
- Department of Research Laboratory of Kidney Diseases (LR00SP01), Charles Nicolle Hospital; Department of Faculty of Medicine, Tunis El Manar University, Tunis, Tunisia
| | - Lilia Ben Fatma
- Department of Nephrology, Dialysis and Transplantation, La Rabta Hospital, Tunis, Tunisia
| | - Lamia Rais
- Department of Nephrology, Dialysis and Transplantation, La Rabta Hospital, Tunis, Tunisia
| | - Mohamed Karim Zouaghi
- Department of Nephrology, Dialysis and Transplantation, La Rabta Hospital, Tunis, Tunisia
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Abstract
Introduction Introduction: pellagra is a systemic disease due to deficiency of vitamin B3 or tryptophan, its precursor. Vitamin B3 is needed for several metabolic processes, cell signaling, and DNA repair. It is characterized by a classic tetrad of dermatitis, diarrhea, dementia, and death. Pellagra is considered rare nowadays; however, due to the popularity of restrictive diets without necessary supplementation such us veganism, there has been an increase in cases in recent years. Clinical case: we report the case of a young strict vegan female patient in which a pellagra diagnosis was made, and early treatment was administered with an excellent outcome. Discussion: the interest of this case lies in the importance of clinical suspicion and directed history taking focused on social and nutritional factors, as adapted for the current times, in order to make the diagnosis of a rare, subdiagnosed disease that is life-threatening if treatment is delayed.
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Diaconescu S, Strat S, Balan GG, Anton C, Stefanescu G, Ioniuc I, Stanescu AMA. Dermatological Manifestations in Pediatric Inflammatory Bowel Disease. Medicina (B Aires) 2020; 56:medicina56090425. [PMID: 32842528 PMCID: PMC7559248 DOI: 10.3390/medicina56090425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/09/2020] [Accepted: 08/21/2020] [Indexed: 12/24/2022] Open
Abstract
Background and Objectives: Over the last years, inflammatory bowel disease (IBD) has been reported on a high incidence in pediatric populations and has been associated with numerous extraintestinal manifestations, making its management a real challenge for the pediatric gastroenterologist. Dermatological manifestations in IBD are either specific, related to the disease activity or treatment-associated, or non-specific. This literature review aims to identify and report the dermatological manifestations of IBD in children, the correlation between their appearance and the demographical characteristics, the relationship between these lesions and disease activity, and to highlight the impact of dermatological manifestations on an IBD treatment regime. Materials and Methods: A systemic literature review was performed, investigating articles and case reports on dermatological manifestations in children with IBD starting from 2005. A total of 159 potentially suitable articles were identified and after the exclusion process, 75 articles were selected. Results: The most common dermatological manifestations reported in pediatric IBD are erythema nodosum and pyoderma gangrenosum. More rare cases of metastatic Crohn’s disease, epidermolysis bullosa acquisita, small-vessel vasculitis, necrotizing vasculitis, leukocytoclastic vasculitis, cutaneous polyarteritis nodosa, and Sweet’s syndrome have been reported. Oral manifestations of IBD are divided into specific (tag-like lesions, mucogingivitis, lip swelling with vertical fissures, aphthous stomatitis, and pyostomatitis vegetans) and non-specific. IBD treatment may present with side effects involving the skin and mucosa. Anti-tumor necrosis factor agents have been linked to opportunistic skin infections, psoriasiform lesions, and a potentially increased risk for skin cancer. Cutaneous manifestations such as acrodermatitis enteropathica, purpuric lesions, and angular cheilitis may appear secondary to malnutrition and/or malabsorption. Conclusions: The correct diagnosis of dermatological manifestations in pediatric IBD is of paramount importance because of their impact on disease activity, treatment options, and a patient’s psychological status.
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Affiliation(s)
- Smaranda Diaconescu
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (S.D.); (I.I.)
- Clinical Department of Pediatric Gastroenterology, “St. Mary” Emergency Children’s Hospital, 700309 Iasi, Romania
| | - Silvia Strat
- Clinical Department of Pediatric Gastroenterology, “St. Mary” Emergency Children’s Hospital, 700309 Iasi, Romania
- Correspondence: ; Tel.: +40-768-035-458
| | - Gheorghe G. Balan
- Gastroenterology and Hepatology Clinic, “St. Spiridon” Emergency Hospital, 700111 Iasi, Romania; (G.G.B.); (C.A.); (G.S.)
- Department of Gastroenterology and Hepatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Carmen Anton
- Gastroenterology and Hepatology Clinic, “St. Spiridon” Emergency Hospital, 700111 Iasi, Romania; (G.G.B.); (C.A.); (G.S.)
- Department of Gastroenterology and Hepatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Gabriela Stefanescu
- Gastroenterology and Hepatology Clinic, “St. Spiridon” Emergency Hospital, 700111 Iasi, Romania; (G.G.B.); (C.A.); (G.S.)
- Department of Gastroenterology and Hepatology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Ileana Ioniuc
- Department of Pediatrics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (S.D.); (I.I.)
- Department of Pediatrics, “St. Mary” Emergency Children’s Hospital, 700309 Iasi, Romania
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Mills K, Akintayo O, Egbosiuba L, Dadzie S, Skyles A, Jang K, Fatima S, Fas N. Chronic Diarrhea in a Drinker: A Breakthrough Case of Pellagra in the US South. J Investig Med High Impact Case Rep 2020; 8:2324709620941305. [PMID: 32646238 PMCID: PMC7357129 DOI: 10.1177/2324709620941305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The triad of diarrhea, dementia, and dermatitis constitutes the clinical diagnosis of pellagra. However, most reported cases of pellagra have occurred without all components of the triad. Pellagra was declared eradicated in the United States after an outbreak in the 1920s, and is now considered to be an exceedingly rare diagnosis in developed countries. In this article, we present a case of a 56-year-old man who presented with a significant history of alcohol use and chronic diarrhea. Pellagra was clinically diagnosed based on the triad of diarrhea, cognitive dysfunction, and dermatitis in this malnourished, alcoholic patient. The patient was treated and clinically improved with resolution of his diarrhea and cognitive dysfunction.
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Affiliation(s)
| | | | | | | | | | - Kudo Jang
- Morehouse School of Medicine, Atlanta, GA, USA
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Hegazy AM, Farid AS, Hafez AS, Eid RM, Nasr SM. Hepatoprotective and immunomodulatory effects of copper-nicotinate complex against fatty liver in rat model. Vet World 2019; 12:1903-1910. [PMID: 32095039 PMCID: PMC6989322 DOI: 10.14202/vetworld.2019.1903-1910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/23/2019] [Indexed: 11/18/2022] Open
Abstract
Aim: The current study was designed to evaluate the potential hepatoprotective and immunomodulatory effects of copper-nicotinate complex (CNC) against methionine- and choline-deficient diet (MCDD)-induced fatty liver in rats. Materials and Methods: Forty male Wistar rats were randomly allocated into one of four equal-sized groups (G1-G4). The G1 group was fed a balanced diet and kept under normal conditions; the G2 group received CNC orally at a dose of 0.043 mg/kg body weight, 3 times/week for 4 weeks, and a balanced diet; the G3 group was fed an MCDD for 4 weeks; and the G4 group was fed an MCDD and administered CNC at the same dose and route as G2. Blood samples were collected for the determination of serum enzyme activity. After 4 weeks of treatment, liver specimens were collected for the evaluation of the oxidative/antioxidative markers, cytokine gene expression, and histopathological examination. Results: CNC improved MCDD-induced liver dysfunctions by recovering serum alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyl transferase activities to their normal levels. The glutathione (GSH) level and superoxide dismutase (SOD) activity significantly decreased, while lipid peroxidation (as reflected by malondialdehyde [MDA]) markedly increased in the liver tissue of the MCDD group. After cotreatment with MCDD and CNC, the GSH level and SOD activity markedly increased and the MDA level significantly decreased to return to normal levels. After cotreatment with MCDD and CNC, significant downregulation of the mRNA expression of hepatic interleukin (IL)-1β, IL-4, macrophage inflammatory protein-1α, and monocyte chemoattractant protein-1 genes was found. Moreover, CNC reduced fatty liver complications by reducing the number of hepatic vacuolations, degenerative changes in the hepatocytes, and hemorrhage. Conclusion: CNC has the potential to limit tissue injury and possibly prevent the progression to severe liver disease caused by an MCDD.
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Affiliation(s)
- Ahmed Medhat Hegazy
- Department of Forensic Medicine and Toxicology, Faculty of Veterinary Medicine, Aswan University, Sahari, Airport Way 81528, Aswan, Egypt
| | - Ayman Samir Farid
- Department of Clinical Pathology, Faculty of Veterinary Medicine, Benha University, Moshtohor, Toukh 13736, Qalyubia, Egypt
| | - Ahmed S Hafez
- Department of Pharmacology, Faculty of Veterinary Medicine, Aswan University, Sahari, Airport Way 81528, Aswan, Egypt
| | - Rania M Eid
- Department of Physiology, Faculty of Medicine, Aswan University, Sahari, Airport Way 81528, Aswan, Egypt
| | - Soad M Nasr
- Department of Parasitology and Animal Diseases, National Research Centre, 33 Bohouth Street, Post Box 12622, Dokki, Giza, Egypt
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Pellagra in isoniazid preventive and antiretroviral therapy. IDCases 2019; 17:e00550. [PMID: 31193074 PMCID: PMC6515148 DOI: 10.1016/j.idcr.2019.e00550] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 04/30/2019] [Accepted: 04/30/2019] [Indexed: 11/30/2022] Open
Abstract
Pellagra is caused by cellular deficiency of niacin or its precursor amino acid, tryptophan. Isoniazid preventive therapy (IPT) is the administration of isoniazid (INH) to latent tuberculosis (TB) infection affected people preventing advancement to active TB disease. Although potentially life-saving for human immunodeficiency virus (HIV)-infected people with no active TB, IPT is arguably a possible player in pellagra in addition to well-known malnourishment determinants particularly in developing nations where diagnosis is often overlooked or delayed. A case study examines clinical presentation and possible causes of pellagra, in HIV + patient on isoniazid prophylaxis. The 30 year old female on routine antiretroviral therapy presented with diarrhea, abdominal discomfort, painful swallowing, and epigastric pain, facial rash spread on the forehead, nose, cheeks and the chin, upper and lower limbs. Withdrawal of isoniazid, administration of nicotinamide and niacin supplements showed clinical improvement in four weeks. Decreased serum tryptophan in persons living with HIV (PLHIV) under IPT and lack of minimum dietary proteins threshold would be pointers to isoniazid induced pellagra risk. Appropriate dietary intake and counseling ought to be emphasized among PLHIV. Tryptophan and nicotinamide serum levels should be part of baseline investigations in PLHIV starting IPT and where feasible clinically, niacin/nicotinamide supplementation be adopted.
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Ng E, Neff M. Recognising the return of nutritional deficiencies: a modern pellagra puzzle. BMJ Case Rep 2018; 11:11/1/e227454. [PMID: 30567139 DOI: 10.1136/bcr-2018-227454] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 34-year-old previously well woman presented with a 4-week history of diffuse erythema and crusting of skin affecting all four limbs. Examination revealed erythematous skin plaques associated with ulceration and fissuring affecting sun-exposed areas of all four limbs primarily on the dorsal surfaces, and a body mass index of 17 kg/m2 She was admitted under the infectious diseases unit, and an autoimmune and infective screen was performed which returned unremarkable. Dietetic consultation led to the diagnosis of severe protein-energy malnutrition, consequent to a severely restricted, primarily vegan, diet. Analysis of the patient's reported diet with nutritional software revealed grossly suboptimal caloric intake with risk of inadequacy for most micronutrients, vitamins and minerals, including niacin. Oral thiamine, multivitamin, iron supplementation and vitamin B complex were started, and a single intramuscular vitamin B12 dose was administered. Marked improvement was seen after 6 weeks, with near-complete resolution of skin changes. These findings supported a diagnosis of pellagra.
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Affiliation(s)
- Elisabeth Ng
- Department of General Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Madeleine Neff
- Department of Nutrition, Alfred Health, Melbourne, Victoria, Australia
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Hui S, Heng L, Shaodong W, Fangyu W, Zhenkai W. Pellagra affecting a patient with Crohn's disease. An Bras Dermatol 2018; 92:879-881. [PMID: 29364456 PMCID: PMC5786414 DOI: 10.1590/abd1806-4841.20174461] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 06/10/2016] [Indexed: 11/21/2022] Open
Abstract
Pellagra is a nutritional disease caused by a deficiency of niacin. It may lead
to death if not identified and treated timely. We review the literature and
report a female patient presented with clinical features of pellagra as a
complication of Crohn's disease.
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Affiliation(s)
- Shi Hui
- Department of Gastroenterology and Hepatology, Jinling Hospital, China
| | - Lu Heng
- Department of Gastroenterology and Hepatology, Jinling Hospital, China
| | - Wang Shaodong
- Department of Gastroenterology and Hepatology, Jinling Hospital, China
| | - Wang Fangyu
- Department of Gastroenterology and Hepatology, Jinling Hospital, China
| | - Wang Zhenkai
- Department of Gastroenterology and Hepatology, Jinling Hospital, China
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Luthe SK, Sato R. Alcoholic Pellagra as a Cause of Altered Mental Status in the Emergency Department. J Emerg Med 2017; 53:554-557. [PMID: 28736097 DOI: 10.1016/j.jemermed.2017.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 04/10/2017] [Accepted: 05/07/2017] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
| | - Ryota Sato
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Okinawa, Japan
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Scaly Erythematous Acral Eruption. Am J Dermatopathol 2016; 38:77-8. [DOI: 10.1097/dad.0000000000000246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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