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Yogi TN, B.C. P, Bhusal A, Limbu S, Kafle R. Alcoholic pellagrous encephalopathy: a case report on atypical presentation and diagnostic dilemma in alcohol-related disorders. Ann Med Surg (Lond) 2024; 86:501-506. [PMID: 38222748 PMCID: PMC10783386 DOI: 10.1097/ms9.0000000000001497] [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: 09/10/2023] [Accepted: 11/01/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction Alcohol use disorder is a global health concern with various complications, including pellagra, often overlooked due to its rarity. This case explores the neurological presentation of pellagra in a long-term alcohol and substance abuser, emphasizing the diagnostic challenges in resource-constrained settings. Case presentation A 36-year-old male with a history of substance abuse presented with multiple symptoms, including hallucinations and neurological deficits. His complex clinical history included alcohol dependence, seizures, and relapses. Physical and neurological examinations revealed characteristic signs of pellagrous encephalopathy. Laboratory findings confirmed anemia and a fatty liver. Discussion Alcoholic pellagrous encephalopathy (APE) presents a diagnostic challenge due to its atypical symptoms, overlapping with other alcohol-related disorders. Niacin deficiency, central to its pathogenesis, affects neurotransmitter synthesis, contributing to neurological symptoms. Diagnosis relies on clinical presentation, but laboratory tests for niacin levels can aid in confirmation. Neuroimaging can exclude alternative causes. This case underscores the importance of considering pellagrous encephalopathy in alcohol-related disorders with neurological symptoms. Conclusion This case underscores the importance of recognizing atypical presentations of APE in chronic alcohol-dependent individuals. Prompt diagnosis, nutritional correction, and addressing alcohol use are vital for successful management. Healthcare providers must be aware of the diagnostic complexities and socioeconomic barriers hindering timely intervention in APE.
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Affiliation(s)
| | - Pooja B.C.
- Department of Psychiatry, BP Koirala Institute of Health Sciences (BPKIHS), Nepal
| | - Amrit Bhusal
- Department of Psychiatry, BP Koirala Institute of Health Sciences (BPKIHS), Nepal
| | - Suren Limbu
- Department of Psychiatry, BP Koirala Institute of Health Sciences (BPKIHS), Nepal
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Novaes ACGDS, Sanches RT, Souza JM, Carneiro ZSDM, Junior JAF, Costa NF. Pellagra and alcoholism: case report. REVISTA CIÊNCIAS EM SAÚDE 2022. [DOI: 10.21876/rcshci.v12i4.1292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Pellagra is mainly caused by a niacin deficiency or its precursor amino acid, tryptophan. We report a case of a male patient, 34 years old, a chronic alcoholic with delirium tremens and gastrointestinal symptoms (diarrhea, inappetence, and heartburn). He presented erythematous-brown, scaly, and well-defined plaques dispersed throughout the integument (photo-exposed areas) for 2 months that evolved with ulceration and hematic crusts. The case was diagnosed as pellagra associated with secondary bacterial infection and treated with rest, an unrestricted diet, B-complex replacement, abstention from alcohol, restriction of sun exposure, and broad-spectrum antibiotic therapy. The treatment allowed for significant improvement of symptoms in one week. Aspects of the pathophysiology and differential diagnoses of this condition are discussed, reinforcing the importance of considering pellagra in diagnosing patients with skin lesions associated with risk factors for malnutrition.
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Wu H, Shen Y, Zhang L, Yang M, Ren Y, Mao F, Wu Z. Erythrodermic Psoriasis in a Patient with Plaque Psoriasis Who Presented with Symptoms of Niacin Deficiency: A Special Case Report. CLINICAL, COSMETIC AND INVESTIGATIONAL DERMATOLOGY 2022; 15:2097-2100. [PMID: 36213316 PMCID: PMC9532255 DOI: 10.2147/ccid.s378591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/14/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Hao Wu
- Department of Dermatology, Ningbo No.6 Hospital, Ningbo, People’s Republic of China
| | - Yanna Shen
- Department of Dermatology, Ningbo No.6 Hospital, Ningbo, People’s Republic of China
| | - Li Zhang
- Department of Dermatology, Ningbo No.6 Hospital, Ningbo, People’s Republic of China
| | - Mouzhe Yang
- Department of Dermatology, Ningbo No.6 Hospital, Ningbo, People’s Republic of China
| | - Yougang Ren
- Department of Dermatology, Ningbo No.6 Hospital, Ningbo, People’s Republic of China
| | - Feng Mao
- Department of Dermatology, Ningbo No.6 Hospital, Ningbo, People’s Republic of China
| | - Zhongxiao Wu
- Department of Dermatology, Ningbo No.6 Hospital, Ningbo, People’s Republic of China
- Correspondence: Zhongxiao Wu, Department of Dermatology, Ningbo No.6 Hospital, No. 1059, Zhongshan East Road, Ningbo, People’s Republic of China, Email
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Chen X, Yang C, Du C, Jiang G. Clinical analysis of alcoholic pellagra: A single-center retrospective study. J Cosmet Dermatol 2022; 21:4707-4713. [PMID: 35500141 DOI: 10.1111/jocd.15036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 02/18/2022] [Accepted: 04/26/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pellagra caused by niacin deficiency in alcoholics can be easily misdiagnosed because of similar symptoms to other alcohol-related diseases and the lack of the classical triad of signs. AIM This study aimed to define the clinical presentation of alcoholic pellagra for early diagnosis and timely treatment. METHODS The clinical data of 16 alcohol-dependent patients who had pellagra and treated in our hospital from January 2002 to December 2019 were retrospectively analyzed. The local medical ethics committee approval (Medical Ethics Committee of Affiliated Hospital of XuZhou Medical University, XYFY2020-KL247-02) for this study have been obtained. RESULTS The main complaints of the 16 patients were skin lesions (six cases), diarrhea (six cases), and mental disorders (four cases). Then, 13 cases had typical skin lesions, and 3 patients had a full spectrum of diarrhea, dementia, and dermatitis (3D). In terms of the main diagnosis, 2 patients had pellagra and Wernicke's encephalopathy, 3 patients had pellagra and alcohol-withdrawal syndrome, and the other patients had pellagra. After sufficient amounts of niacin and multivitamin B were given, clinical symptoms improved rapidly, and no sequelae were observed during follow-up. CONCLUSIONS Pellagra is rarely manifested as a full 3D spectrum, with only one or two characteristics, which lack diagnostic specificity, especially in individuals with alcoholism. Physicians should maintain a high degree of suspicion of niacin deficiency in alcoholics. Alcohol-dependent patients with pellagra may be accompanied by complications of Wernicke's encephalopathy and alcohol-withdrawal syndrome. Prompt identification and timely treatment with a sufficient amount of niacin in combination with other vitamins and a certain amount of Zn can achieve a good prognosis of pellagra.
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Affiliation(s)
- Xi Chen
- Department of Dermatology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, China.,Department of Dermatology, Huzhou First People's Hospital, Zhejiang223002, China
| | - Chunsheng Yang
- Department of Dermatology, Affiliated Huai'an Hospital of Xuzhou Medical University, The second peoples Hospital of Huai'an, Huai, 223002, China
| | - Chichi Du
- Department of Dermatology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, China
| | - Guan Jiang
- Department of Dermatology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, China
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Heirene RM, John B, O’Hanrahan M, Angelakis I, Roderique-Davies G. Professional Perspectives on Supporting Those with Alcohol-Related Neurocognitive Disorders: Challenges & Effective Treatment. ALCOHOLISM TREATMENT QUARTERLY 2021. [DOI: 10.1080/07347324.2021.1898294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Robert M. Heirene
- Brain & Mind Centre, School of Psychology, University of Sydney, Sydney, Australia
- Addictions Research Group, University of South Wales, School of Psychology & Therapeutic Studies, Pontypridd, UK
| | - Bev John
- Addictions Research Group, University of South Wales, School of Psychology & Therapeutic Studies, Pontypridd, UK
| | - Marie O’Hanrahan
- Addictions Research Group, University of South Wales, School of Psychology & Therapeutic Studies, Pontypridd, UK
| | - Ioannis Angelakis
- Addictions Research Group, University of South Wales, School of Psychology & Therapeutic Studies, Pontypridd, UK
| | - Gareth Roderique-Davies
- Addictions Research Group, University of South Wales, School of Psychology & Therapeutic Studies, Pontypridd, UK
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Cao S, Wang X, Cestodio K. Pellagra, an Almost-Forgotten Differential Diagnosis of Chronic Diarrhea: More Prevalent Than We Think. Nutr Clin Pract 2019; 35:860-863. [PMID: 31599018 DOI: 10.1002/ncp.10418] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Pellagra, caused by vitamin B3 (niacin) deficiency, is traditionally described as dermatitis, diarrhea, dementia (3D), and even death (4D) syndrome if not recognized and treated promptly. Although full-blown pellagra with all 3D features has become rare, pellagra still exists, especially in high-risk populations, which is actually more prevalent than we think. We report that a recently treated patient with the full spectrum of 3D clinical features of pellagra presents as chronic diarrhea of unknown etiology for 1 year. It reminds us that keeping a high index of suspicion and maintaining a broad differential diagnosis are critical for recognition and management of this potentially fatal but treatable condition.
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Affiliation(s)
- Shanjin Cao
- Department of Hospitalist, Charlton Memorial Hospital, Fall River, MA, USA.,Department of Hospitalist, Prima CARE, P.C., Fall River, MA, USA
| | - Xiaodan Wang
- Department of Hospitalist, Charlton Memorial Hospital, Fall River, MA, USA.,Department of Hospitalist, Prima CARE, P.C., Fall River, MA, USA
| | - Kristen Cestodio
- Department of Hospitalist, Charlton Memorial Hospital, Fall River, MA, USA.,Department of Hospitalist, Prima CARE, P.C., Fall River, MA, USA
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Narasimha VL, Ganesh S, Reddy S, Shukla L, Mukherjee D, Kandasamy A, Chand PK, Benegal V, Murthy P. Pellagra and Alcohol Dependence Syndrome: Findings From a Tertiary Care Addiction Treatment Centre in India. Alcohol Alcohol 2019; 54:148-151. [PMID: 30721993 DOI: 10.1093/alcalc/agz004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/12/2018] [Accepted: 01/09/2019] [Indexed: 01/10/2023] Open
Abstract
AIM To define the prevalence and clinical presentation of pellagra, a multi-systemic disease caused by the deficiency of niacin, in patients admitted to a tertiary addiction treatment centre in southern India, with alcohol dependence syndrome (ADS)-(ICD10). METHODS Review of the health records of 2947 patients who received inpatient care for ADS between 2015 and 2017. RESULTS Out of 2947, 31 (1%) were diagnosed with pellagra. Nearly two-thirds (64.5%) of those with pellagra were from a low-income group. Of the clinical-triad of pellagra, all patients had dermatitis, more than half (58%) had delirium, a minority (19%) had diarrhoea. Nearly two-thirds (61%) had presented in a complicated-withdrawal state. Associated conditions included peripheral neuropathy (32%); Wernicke's encephalopathy (26%); seizures (16%).Seventeen (54%) had BMI <18.5 kg/m2. Treatment was a high dose of parenteral vitamins including niacin (mean dose: 1500 mg/day) for an average of 7.5 days followed by oral multivitamin supplements. All had complete resolution of pellagrous symptoms by the end of the three weeks of inpatient care. CONCLUSIONS Pellagra is an acute medical condition, frequently encountered in the context of alcohol dependence and poverty. It often presents with other disabling and life-threatening comorbidities like delirium tremens and Wernicke's encephalopathy. The classical triad of pellagra is only seen in a minority of cases. Thus a high index of suspicion is required lest pellagra may remain undiagnosed. Prompt identification and treatment with a high dose of niacin in combination with other vitamins result in complete recovery.
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Affiliation(s)
- Venkata Lakshmi Narasimha
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, India
| | - Suhas Ganesh
- Schizophrenia Neuropharmacology Research Group at Yale (SNRGY), Department of Psychiatry, Yale University, New Haven, CT, USA
| | - Sarath Reddy
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, India
| | | | - Diptadhi Mukherjee
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, India
| | - Arun Kandasamy
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, India
| | - Prabhat K Chand
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, India
| | - Vivek Benegal
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, India
| | - Pratima Murthy
- Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru, India
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Priani E. 'Shrouded in a dark fog': comparison of the diagnosis of pellagra in Venice and general paralysis of the insane in the United Kingdom, 1840-1900. HISTORY OF PSYCHIATRY 2017; 28:166-181. [PMID: 28468544 DOI: 10.1177/0957154x17693724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The debate on the causes and the nature of pellagra in Italy during the nineteenth century resembles and evokes the similar debate on General Paralysis of the Insane (GPI) that was growing at the same time in the United Kingdom. Pellagra and GPI had a massive and virulent impact on the populations of Italy and the UK, respectively, and contributed to a great extent to the increase and overcrowding of the asylum populations in these countries. This article compares the two illnesses by examining the features of their nosographic positioning, aetiology and pathogenesis. It also documents how doctors arrived at the diagnoses of the two diseases and how this affected their treatment.
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Erriu M, Pili FMG, Cadoni S, Garau V. Diagnosis of Lingual Atrophic Conditions: Associations with Local and Systemic Factors. A Descriptive Review. Open Dent J 2016; 10:619-635. [PMID: 27990187 PMCID: PMC5123136 DOI: 10.2174/1874210601610010619] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 10/09/2016] [Accepted: 10/15/2016] [Indexed: 12/16/2022] Open
Abstract
Atrophic glossitis is a condition characterised by absence of filiform or fungiform papillae on the dorsal surface of the tongue. Consequently, the ordinary texture and appearance of the dorsal tongue, determined by papillary protrusion, turns into a soft and smooth aspect. Throughout the years, many factors, both local and systemic, have been associated with atrophic glossitis as the tongue is currently considered to be a mirror of general health. Moreover, various tongue conditions were wrongly diagnosed as atrophic glossitis. Oral involvement can conceal underlying systemic conditions and, in this perspective, the role of clinicians is fundamental. Early recognition of oral signs and symptoms, through a careful examination of oral anatomical structures, plays a crucial role in providing patients with a better prognosis.
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Affiliation(s)
- M Erriu
- Department of Surgical Sciences, Cagliari University, Cagliari, Italy
| | - F M G Pili
- Department of Surgical Sciences, Cagliari University, Cagliari, Italy
| | - S Cadoni
- Digestive Endoscopy Unit, S. Barbara Hospital, Iglesias (CA), Italy
| | - V Garau
- Department of Surgical Sciences, Cagliari University, Cagliari, Italy
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11
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Kuy S, Romero RAL, Vincent L, Rose K. Images: perineal pain and malodorous drainage in a patient with rectal cancer. Postgrad Med J 2016; 93:51-52. [DOI: 10.1136/postgradmedj-2016-134210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 06/07/2016] [Accepted: 06/10/2016] [Indexed: 11/04/2022]
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12
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Park K, Oeda T, Sawada H. A case of alcoholic pellagra encephalopathy presenting with spinal myoclonus. Neurol Clin Pract 2015; 5:472-474. [PMID: 29595842 DOI: 10.1212/cpj.0000000000000165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Kwiyoung Park
- Department of Neurology and Clinical Research Center, Utano National Hospital, Kyoto, Japan
| | - Tomoko Oeda
- Department of Neurology and Clinical Research Center, Utano National Hospital, Kyoto, Japan
| | - Hideyuki Sawada
- Department of Neurology and Clinical Research Center, Utano National Hospital, Kyoto, Japan
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Terada N, Kinoshita K, Taguchi S, Tokuda Y. Wernicke encephalopathy and pellagra in an alcoholic and malnourished patient. BMJ Case Rep 2015; 2015:bcr-2015-209412. [PMID: 26490997 DOI: 10.1136/bcr-2015-209412] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Deficiency of multiple vitamins can be identified in alcoholic and malnourished patients. We report a patient with Wernicke encephalopathy, a B1 deficiency and pellagra, a niacin deficiency. A 61-year-old Japanese man presented with generalised weakness. He had drunk alcohol heavily for more than a year without eating adequate meals. Physical examination showed disorientation, eye movement impairment, muscle wasting and a rash over the limbs. Multivitamin supplementations improved all the symptoms. Pellagra causes dementia, diarrhoea, or dermatitis, and can mimic non-specific erythaema in alcoholics. The differential diagnosis between pellagra and non-specific erythaema is important because of the treatability of pellagra by niacin supplementation.
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Affiliation(s)
| | | | | | - Yasuharu Tokuda
- Department of General Internal Medicine, Tsukuba University, Mito, Ibaraki, Japan
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Abstract
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.
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