Pellagra in an immunocompetent patient with cytomegalovirus colitis

Balancing NAD+ deficits with nicotinamide riboside: therapeutic possibilities and limitations

Alterations in cellular nicotinamide adenine dinucleotide (NAD+) levels have been observed in multiple lifestyle and age-related medical conditions. This has led to the hypothesis that dietary supplementation with NAD+ precursors, or vitamin B3s, could exert health benefits. Among the different molecules that can act as NAD+ precursors, Nicotinamide Riboside (NR) has gained most attention due to its success in alleviating and treating disease conditions at the pre-clinical level. However, the clinical outcomes for NR supplementation strategies have not yet met the expectations generated in mouse models. In this review we aim to provide a comprehensive view on NAD+ biology, what causes NAD+ deficits and the journey of NR from its discovery to its clinical development. We also discuss what are the current limitations in NR-based therapies and potential ways to overcome them. Overall, this review will not only provide tools to understand NAD+ biology and assess its changes in disease situations, but also to decide which NAD+ precursor could have the best therapeutic potential.

Alcoholic Pellagra as a Cause of Altered Mental Status in the Emergency Department

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.

An Outbreak of Pellagra in the Kasese Catchment Area, Dowa, Malawi

AbstractPellagra is a deficiency of niacin or its amino acid precursor, tryptophan, which presents with the classic four Ds: the characteristic dermatitis, diarrhea, dementia, and eventually death if left untreated. The incidence of pellagra is quite rare presently because of increased awareness and strategies such as vitamin fortification. However, the deficiency is still present in cultures that rely on maize as their primary source of sustenance. We report a recent outbreak in a catchment area in Kasese, Malawi, of 691 cases of pellagra which were successfully treated with niacin supplementation. We present this short report to highlight the importance of educating providers of at-risk populations about this diagnosis and to consider solutions for these populations to prevent further deficiencies.

A case of pellagra associated with megaduodenum in a young woman

Pellagra is a rare condition that has been known for many years to be related to niacin deficiency. Clinically known as the 4 "D" symptoms for dermatitis, diarrhea, dementia, and even death, skin changes remain one of the most important features of this pathology, leading frequently to the diagnosis. Pellagra is mostly seen in poor populations with a deficient diet; still, it is sporadically observed in developed countries, usually in association with digestive disorders. We report a new case of pellagra in a 29-year-old woman in whom the diagnosis of megaduodenum was made. Megaduodenum is a rare condition that can be idiopathic or secondary to visceral myopathy or neuropathy. Parenteral supplementation with niacin has resulted in a quick response of dermatological and psychiatric symptoms. To our knowledge, no case of pellagra due to megaduodenum has been reported in literature.

Low and deficient niacin status and pellagra are endemic in postwar Angola

BACKGROUND

Outbreaks of pellagra were documented during the civil war in Angola, but no contemporary data on the incidence of pellagra or the prevalence of niacin deficiency were available.

OBJECTIVE

The objective was to investigate the incidence of pellagra and the prevalence of niacin deficiency in postwar Angola and their relation with dietary intake, poverty, and anthropometric status.

DESIGN

Admissions data from 1999 to 2004 from the pellagra treatment clinic in Kuito, Angola, were analyzed. New patients admitted over 1 wk were examined, and urine and blood samples were collected. A multistage cluster population survey collected data on anthropometric measures, household dietary intakes, socioeconomic status, and clinical signs of pellagra for women and children. Urinary excretion of 1-methylnicotinamide, 1-methyl-2-pyridone-5-carboxymide, and creatinine was measured and hemoglobin concentrations were measured with a portable photometer.

RESULTS

The incidence of clinical pellagra has not decreased since the end of the civil war in 2002. Low excretion of niacin metabolites was confirmed in 10 of 11 new clinic patients. Survey data were collected for 723 women aged 15-49 y and for 690 children aged 6-59 mo. Excretion of niacin metabolites was low in 29.4% of the women and 6.0% of the children, and the creatinine-adjusted concentrations were significantly lower in the women than in the children (P < 0.001, t test). In children, niacin status was positively correlated with the household consumption of peanuts (r = 0.374, P = 0.001) and eggs (r = 0.290, P = 0.012) but negatively correlated with socioeconomic status (r = -0.228, P = 0.037).

CONCLUSIONS

The expected decrease in pellagra incidence after the end of the civil war has not occurred. The identification of niacin deficiency as a public health problem should refocus attention on this nutritional deficiency in Angola and other areas of Africa where maize is the staple.

Pellagra: a rare disease observed in a victim of mental and physical abuse

Lesions of the brain stem and cerebellum due to nutritional deficiencies are mostly seen in chronic alcohol abuse and more rarely in severe malnutrition. We report the case of a 27-year-old woman, found dead in the family flat. She presented cachexia (167 cm, 25 kg) and multiple hematomas of the limbs. Postmortem examination revealed lesions due to peritonitis. Neuropathological examination showed severe atrophy of the corpus callosum and central neuronal chromatolysis, which are observed in pellagra. Inflammatory colitis or celiac disease was not found. Toxicological analysis was negative, in particular no alcohol absorption. Pellagra, which is due to nicotinamide deficiency, is a disease rarely seen in this country. In this case, nutritional deficiency was the consequence of failure to eat in a context of abuse. The woman was born of an incestuous relationship and presented intellectual retardation due to poor affective relations with her mother.

Pellagra: dermatitis, dementia, and diarrhea

Pellagra defines systemic disease as resulting from a marked cellular deficiency of niacin. It is characterized by 4 "D's": diarrhea, dermatitis, dementia, and death. Diagnosis of pellagra is difficult in the absence of the skin lesions, and is often facilitated by the presence of characteristic ones. The dermatitis begins as an erythema. Acute pellagra resembles sunburn in its first stages, but tanning occurs more slowly than typically in sunburn. Exacerbation follows re-exposure to sunlight. In this work we review the findings of this once mysterious disorder, one that still challenges clinicians world-wide.

Human cytomegalovirus infection of the gastrointestinal tract in apparently immunocompetent patients

Human cytomegalovirus (HCMV) infection is usually reported in immunocompromised patients. This study reports 11 cases of HCMV infection of the gastrointestinal (GI) tract diagnosed in apparently immunocompetent hosts. The median age of the patients studied was 76 years, and the major presenting symptoms were diarrhea, epigastric pain, and abdominal discomfort. The large intestine was involved in 6 cases, the stomach in 4 cases, and the lower esophagus in 1 case. Endoscopy revealed ulcers or hypertrophic folds in the GI tract and single ulcers or erosions in the colon and rectum. Light microscopy showed chronic inflammatory infiltrate in the lamina propria in all cases. The diagnosis of HCMV infection was based on the histological and immunohistochemical identification of HCMV inclusion bodies in different cell types, including epithelial, endothelial, stromal, and smooth muscle cells. Both "classical" inclusions, characterized by an "owl's eye" appearance, and atypical inclusions were found. For all patients, no apparent causes of immunodeficiency were detected at the time of diagnosis of HCMV infection. At follow-up, however, 4 patients were found to harbor a malignant tumor (ie, pancreas, lung, Vater's papilla, and extrahepatic bile duct) at an interval of 2 to 5 months after the diagnosis of HCMV infection. Especially in elderly patients, HCMV infection of the GI tract might be an early clue to the presence of immunologic defects induced by an underlying neoplasia.