Clinical analysis of alcoholic pellagra: A single-center retrospective study.

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 has 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.

COVID-19: Are We Facing Secondary Pellagra Which Cannot Simply Be Cured by Vitamin B3?

Immune response to SARS-CoV-2 and ensuing inflammation pose a huge challenge to the host's nicotinamide adenine dinucleotide (NAD+) metabolism. Humans depend on vitamin B3 for biosynthesis of NAD+, indispensable for many metabolic and NAD+-consuming signaling reactions. The balance between its utilization and resynthesis is vitally important. Many extra-pulmonary symptoms of COVID-19 strikingly resemble those of pellagra, vitamin B3 deficiency (e.g., diarrhoea, dermatitis, oral cavity and tongue manifestations, loss of smell and taste, mental confusion). In most developed countries, pellagra is successfully eradicated by vitamin B3 fortification programs. Thus, conceivably, it has not been suspected as a cause of COVID-19 symptoms. Here, the deregulation of the NAD+ metabolism in response to the SARS-CoV-2 infection is reviewed, with special emphasis on the differences in the NAD+ biosynthetic pathway's efficiency in conditions predisposing for the development of serious COVID-19. SARS-CoV-2 infection-induced NAD+ depletion and the elevated levels of its metabolites contribute to the development of a systemic disease. Acute liberation of nicotinamide (NAM) in antiviral NAD+-consuming reactions potentiates "NAM drain", cooperatively mediated by nicotinamide N-methyltransferase and aldehyde oxidase. "NAM drain" compromises the NAD+ salvage pathway's fail-safe function. The robustness of the host's NAD+ salvage pathway, prior to the SARS-CoV-2 infection, is an important determinant of COVID-19 severity and persistence of certain symptoms upon resolution of infection.

Pelagra: una enfermedad antigua en un mundo moderno / Pellagra: an ancient disease in a modern world

Introducción: la pelagra es una enfermedad sistémica secundaria a la deficiencia de vitamina B3 o de su precursor, el triptófano. La vitamina B3 es necesaria para varios procesos metabólicos, de señalización celular y reparación del ADN. Se caracteriza por la tétrada clásica de dermatitis, diarrea, demencia y muerte. La misma es considerada una enfermedad rara hoy en día; sin embargo, con el auge de las dietas restrictivas sin la adecuada suplementación, como es el caso del veganismo, se ha visto un aumento de los casos en los últimos años. Caso clínico: exponemos el caso de una paciente adulta joven, vegana estricta, a la cual se le realizó el diagnóstico de pelagra y se le instauró un tratamiento de forma precoz, con una excelente evolución. Discusión: el interés del caso radica en la importancia de la sospecha clínica y la anamnesis dirigida a factores sociales y nutricionales, adaptados a la época actual, para poder hacer el diagnóstico de una enfermedad rara e infradiagnosticada que es potencialmente mortal de retrasarse el inicio del tratamiento. (AU)

Background: 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. Case report: 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. (AU)

Cyclone Idai as a Trigger for Pellagra Outbreak in Nhamatanda, Mozambique: A Case-Control Study.

In mid-June 2019, 3 months after cyclone Idai landfall in Mozambique, health authorities of Nhamatanda district reported an outbreak of Pellagra. Applying a mixed-method protocol, we carried out an investigation to characterize cases of pellagra, identify the associated factors for the outbreak using a case-control study, and explore the perceived impact on food security (availability, access, and usage) before and after Idai. We collected data from 121 cases and 121 controls and conducted in-depth interviews with 69 heads of households. The cases were more likely to be female (P < 0.01) and less educated (P < 0.01) than controls. Insufficient consumption of chicken and peanut before cyclone Idai arrival were statistically associated with pellagra (P < 0.05). From interviewed households' heads, 51% were experiencing food shortages even before the cyclone hit. Cyclone Idai served as a trigger to reduce niacin consumption below the threshold that protected Nhamatanda population from pellagra and caused a ≈2,300 case (707.9/100,000 inhabitants) outbreak.

[Pellagra: an ancient disease in a modern world]. / Pelagra: una enfermedad antigua en un mundo moderno.

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.

INTRODUCCIÓN: Introducción: la pelagra es una enfermedad sistémica secundaria a la deficiencia de vitamina B3 o de su precursor, el triptófano. La vitamina B3 es necesaria para varios procesos metabólicos, de señalización celular y reparación del ADN. Se caracteriza por la tétrada clásica de dermatitis, diarrea, demencia y muerte. La misma es considerada una enfermedad rara hoy en día; sin embargo, con el auge de las dietas restrictivas sin la adecuada suplementación, como es el caso del veganismo, se ha visto un aumento de los casos en los últimos años. Caso clínico: exponemos el caso de una paciente adulta joven, vegana estricta, a la cual se le realizó el diagnóstico de pelagra y se le instauró un tratamiento de forma precoz, con una excelente evolución. Discusión: el interés del caso radica en la importancia de la sospecha clínica y la anamnesis dirigida a factores sociales y nutricionales, adaptados a la época actual, para poder hacer el diagnóstico de una enfermedad rara e infradiagnosticada que es potencialmente mortal de retrasarse el inicio del tratamiento.

Pellagra a review exploring causes and mechanisms, including isoniazid-induced pellagra.

Pellagra is a clinical syndrome caused by a deficiency of niacin (nicotinic acid) and/or its precursor tryptophan. The cardinal manifestations are 4 D's: dermatitis, diarrhoea, dementia and in worst case death. Increased use of isoniazid prophylaxis along with antiretroviral therapy in countries where latent tuberculosis is common has been associated with increased presentations with pellagra.

[Cutaneous manifestations of nutritional deficiencies]. / Manifestations cutanées de carences nutritionnelles, ou quand l'examen de la peau alimente le diagnostic.

In elderly or chronically ill patients, nutritional deficiencies are common and the presence of related skin lesions is not unusual. Recognition of such cutaneous involvement is important regarding the diagnosis essentially based on clinical elements. By using some clinical case reports, we will describe several pathologies related to nutritional deficiencies like scurvy, pellagra and acquired acrodermatitis enteropathica.

Dans nos populations de patients vieillissants ou atteints de maladies chroniques, les carences nutritionnelles sont fréquentes et la présence de manifestations dermatologiques associées n'est pas rare. La reconnaissance de telles atteintes cutanées est importante pour le diagnostic qui est essentiellement clinique. A l'aide de vignettes cliniques, nous allons discuter ici de pathologies carentielles comme le scorbut, la pellagre ainsi que l'acrodermatite entéropathique acquise.

Pellagra affecting a patient with Crohn's disease

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.

Pellagra affecting a patient with Crohn's disease.

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.

Louis Sambon and the Clash of Pellagra Etiologies in Italy and the United States, 1905-14.

This article explores the extent to which the bacterial concept of disease acted as an obstacle to the understanding of deficiency diseases, by focusing on explorations into the cause of pellagra in the early twentieth century. In 1900, pellagra had been epidemic in Italy for 150 years and was soon to become so in the United States, yet the responses of medical investigators differed substantially. To account for these, the article reconstructs the sharply contrasting reactions to a provocative theory proposed by Louis Sambon. Applying a tropical diseases approach to pellagra, Sambon argued that pellagra had nothing at all to do with maize consumption, as the Italians had long thought, but was caused by the bite of a parasite-carrying insect. Italian pellagrologists, involved in a dogmatic quest for a toxin in maize, and with pellagra rates there on the decline, marginalized the Sambon hypothesis. By contrast, in the United States, with pellagra on the rise, the dominant infectious paradigm put Sambon center stage, his proposed etiology shaping the earliest American investigations. When the deficiency disease concept gained currency in 1913, the relatively closed world of Italian pellagrology was wrong-footed, while the more open-ended U.S. community was better able to follow up the new lead. The article discusses what these shifts and the resulting controversies reveal about the medical contexts. The actor-centered approach, with reaction to Sambon's intervention as a kind of test-case, is the key to understanding these controversies and why they mattered.

[An Uncommon Diagnosis]. / Eine nicht alltägliche Diagnose.

We report on a 61-year-old patient who suffered from severe protein-energy malnutrition due to an inadequately treated exocrine pancreatic insufficiency. In this context, a thiamine deficiency was not recognized and there were clinical manifestations of beriberi disease with decompensated biventricular heart failure. In the course of time, a manifest niacin deficiency (pellagra) with dermatitis, diarrhea and persistent delirium occurred, which was recognized and could be treated. We highlight differential diagnostic considerations about the consequences and the treatment of malnutrition, with special focus on the classical deficiency diseases beriberi and pellagra.

[Niacin deficiency and cutaneous immunity].

Niacin, also known as vitamin B3, is required for the synthesis of coenzymes, nicotinamide adenine dinucleotide (NAD) and nicotinamide adenine dinucleotide phosphate (NADP). Niacin binds with G protein-coupled receptor (GPR) 109A on cutaneous Langerhans cells and causes vasodilation with flushing in head and neck area. Niacin deficiency due to excessive alcohol consumption, certain drugs or inadequate uptake in diet causes pellagra, a photosensitivity dermatitis. Recently several studies have revealed the mechanism of photosensitivity in niacin deficiency, which may pave a way for new therapeutic approaches. The expression level of prostaglandin E synthase (PTGES) is up-regulated in the skin of both pellagra patients and niacin deficient pellagra mouse models. In addition, pellagra is mediated through prostaglandin E2-EP4 (PGE2-EP4) signaling via reactive oxygen species (ROS) production in keratinocytes. In this article, we have reviewed the role of niacin in immunity and the mechanism of niacin deficiency-induced photosensitivity.

Pellagra in a patient with primary Sjögren's syndrome.

A 27-year-old woman presented with persistent dryness of the mouth and eyes. She presented with permanent photodistributed rash involving the face and distal extremities. Laboratory tests showed positive Sjögren's syndrome (SS)-A and SS-B antibodies. Histological examination of minor salivary gland biopsy revealed inflammatory infiltration grade 4 according to Chisholm's classification. Skin biopsy showed acanthosis, hyperkeratosis in the epidermis and little inflammatory infiltrate in the dermis. There was an infiltration of CD4 T lymphocytes in the dermis. Based on the characteristics of the dermatitis and on a rapid response to niacin replacement, the diagnosis of pellagra was carried out. A complete resolution of the dermatological signs was obtained within 2 months. To the best of our knowledge, the association between primary SS and pellagra has never been reported. We emphasise the possible mechanisms of this association.