What are the other Names for this Condition? (Also known as/Synonyms)

• Alpine Scurvy
• Typhoid Pellagra
• Vitamin B3 Deficiency

What is Pellagra? (Definition/Background Information)

• Pellagra is a Vitamin B3 Deficiency disorder caused by poor intake of dietary vitamin B3
• The condition manifests as 4 “Ds”, which indicate dermatitis, diarrhea, dementia, and death. All the 4 manifestations may not occur in an individual; although if the condition is left untreated, it may be fatal
• This disease used to be prevalent in poor socioeconomic sections of the society, whose staple diet (of corn and maize) was lacking in vitamin B3 (or niacin)
• Pellagra is classified into two types:
  • Primary Pellagra, which is caused by dietary deficiency of niacin
  • Secondary Pellagra, which is caused by the malabsorption of niacin resulting from some underlying diseases or conditions, the use of certain medications, etc.
• Vitamin B3 or niacin is used by the body to metabolize food into energy. The vitamin also acts as a scavenger and removes the free oxygen radicals, thus preventing damage to the intracellular proteins
• Oral supplementation of niacin can reverse the clinical manifestations of the deficiency disorder and correct the condition. This is also indicative of Pellagra

Who gets Pellagra? (Age and Sex Distribution)

• Pellagra commonly occurs in adults, though it may sometimes occur in adolescents and older children
• There is no sexual predilection; both male and female genders are affected
• It was commonly seen in developing countries where the staple diet is maize and untreated corn. Presently, Pellagra is mostly confined to certain regions of Africa (Angola, Mozambique) and Asia (Nepal)

What are the Risk Factors for Pellagra? (Predisposing Factors)

Risk factors of Pellagra are:

• People belonging to economical weaker classes may not have access to well-balanced diets
• Those who regularly have diets rich in maize and corn
• Diseases of the digestive tract causing malabsorption
• Chronic alcoholics and illegal drug abusers

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Pellagra? (Etiology)

• Severe niacin and/or tryptophan deficiency causes Pellagra. Niacin (vitamin B3) and tryptophan (an essential amino acid) are obtained from the diet
• Primary Pellagra results from inadequate nicotinic acid (niacin) and/or tryptophan intake in the diet
• Secondary Pellagra results from various health conditions that interfere with the absorption of niacin in the body, even though there is adequate dietary intake of the vitamin. Such conditions include:
  • Prolonged diarrhea
  • Adrenal pheochromocytoma
  • Disorders, such as ulcerative colitis, Crohn’s disease, and tuberculosis of the GI tract, affecting the digestive system
  • Long-term alcoholism
  • Liver cirrhosis      
  • Chronic dialysis treatment
  • Malignant carcinoid tumor
  • Hartnup disease (causing a defect in the metabolism of tryptophan)

What are the Signs and Symptoms of Pellagra?

Common signs and symptoms associated with Pellagra include:

• Scaly skin sores; Skin sores resemble sunburn and gradually subside, leaving a dusky, brown-red skin discoloration
• The skin lesions are painful with burning sensation, but itching may or may not be present
• Inflamed mucous membranes
• Diarrhea
• Weakness, loss of appetite
• Confusion and irritability

How is Pellagra Diagnosed?

The diagnosis of Pellagra may involve:

• Complete evaluation of medical history along with a thorough physical examination
• Blood tests such as:
  • Complete blood count (which may indicate anemia)
  • Serum protein (levels may be low)
  • Serum calcium (higher levels observed)
  • Serum potassium and phosphorus (both minerals may be low)           
• Liver function test: The deficiency disorder may be indicated by low blood levels of niacin, tryptophan, NAD, and NADP
• Urine test: Deficient niacin levels may be indicated by low levels of N- methylnicotinamide and pyridine, which can help confirm Pellagra. The severity of the deficiency is indicated by the amount secreted through urine (less than 1.5 mg in 24 hours means severe condition)

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Pellagra?

The complications of Pellagra include:

• Permeant hyperpigmentation of the skin
• Difficulty swallowing due to mouth inflammation
• Depression and anxiety
• Delusion, hallucination
• Dilated cardiomyopathy: It is a heart muscle disorder that leads to enlarged and weakened chambers of the heart
• Coma

How is Pellagra Treated?

Oral supplementation of niacin can help control the signs and symptoms, reverse the condition, and correct the deficiency situation arising from Pellagra.

• A diet with adequate calories rich in meat, milk, peanuts, green leafy vegetables (such as spinach and broccoli), and whole grains is recommended
• For individuals with mouth inflammation and swallowing difficulties, a liquid or a semisolid diet may be suggested
• Bed rest is mandatory in treating patients with severe Pellagra
• Avoidance of sun exposure is strongly advised

How can Pellagra be Prevented?

• A diet adequately rich in vitamin B3 (niacin) and tryptophan can help prevent Primary Pellagra
• Secondary Pellagra can be prevented by prompt and early treatment of the disorders responsible for causing niacin malabsorption

What is the Prognosis of Pellagra? (Outcomes/Resolutions)

• The prognosis of Pellagra is good with correct diagnosis and appropriate treatment
• The condition can be entirely reversed through adequate niacin and/or tryptophan supplementation
• If left untreated, the condition may progress to a severe deficiency state resulting in complications, which can cause coma and death

Additional and Relevant Useful Information for Pellagra:

The following DoveMed website link is a useful resource for additional information:

https://www.dovemed.com/healthy-living/nutrition-and-dietetics/