Pellagra


Last Updated December 20th, 2021

What is pellagra?

Pellagra is defined as a nutritional disorder which is caused by a vitamin B3 deficiency.  Pellagra leads to different systemic diseases ranging from the skin, stomach, and the nervous system.  

Pellagra syndrome is characterized by Dermatitis, Diarrhea, Dementia, which leads to Death. Patients suffering from pellagra have symptoms of brown discoloration of the skin, especially in sun-exposed areas.  Advanced stages of pellagra cause increased pigmentation, which usually leads to thin varnish-like eruptive scales.  

Apart from skin changes, abdominal involvement may lead to intractable diarrhea, stomatitis (inflammation of the mouth), and glossitis (ulcerations within the mouth), while pellagrous encephalopathy causes memory loss, depression, delirium, or disorientation.  

Pellagra if untreated can lead to stupor and death. The name pellagra comes from the Italian word pelle (skin) and agra (rough), which is rough skin, referring to the skin problems in pellagra.

The discovery of pellagra

The diagnosis of pellagra was solved by Dr. Joseph Goldberger.  Dr. Goldberger was given the responsibility by the US Public Health Service to deal with pellagra.  After inspecting Southern orphanages, mental hospitals and prisons, Dr. Goldberger made the pivotal observation that the malnourished inmates of those institutions often developed pellagra while the better-fed staff did not develop pellagra.

It was concluded by Dr. Goldberger that pellagra did not arise from germs, as was commonly believed, but rather from a nutritional deficiency and to prove this, Dr. Goldberger, his assistants and even his wife engaged in experiments called as filth parties.  They injected themselves with blood or ingested the scabs, feces and body fluids of patients and none developed pellagra. He fed Mississippi prison inmates with a poor diet that he believed caused pellagra and within months, many developed the disease.  He then added meat, fresh vegetables, and milk to their diet and reversed all of the signs and symptoms of pellagra.

He never identified the dietary principle that had this extraordinary effect. Dr. Goldberger died in 1929 due to kidney cancer and eight years later, the factor was found to be niacin, which was made in 1937 at the University of Wisconsin.  Vitamin B3 is found in large quantities in food products such as fish, poultry, red meat, and green leafy vegetables.

Types of pellagra

Pellagra is diagnosed at a later stage of severe niacin deficiency.  Niacin, which is also called vitamin B3, is a water-soluble vitamin.  Pellagra is differentiated into primary and secondary.

  • Primary pellagra results from inadequate nicotinic acid (niacin) and/or tryptophan in the diet.  The body generally converts niacin into an amide, which is required for appropriate cellular function and metabolism.  These compounds are known as vital coenzymes. Since cellular functions in multiple organs and tissues are affected by niacin deficiency, the clinical expressions of pellagra are diverse.
  • Secondary pellagra can be diagnosed when a sufficient amount of niacin is present in the diet, but other diseases alter adequate niacin absorption and/or processing.  Some of the examples include prolonged diarrhea, chronic alcoholism, chronic dialysis treatment, chronic colitis, particularly ulcerative colitis or regional enteritis, cirrhosis of the liver, tuberculosis of the GI tract, malignant carcinoid tumor, and Hartnup syndrome.

Factors affecting the incidence of pellagra

Frequency:  Pellagra occurs mainly in developing nations in which corn and corn products are the major food sources.  Pellagra is common among ethnic populations since their diets are deficient in niacin and/or tryptophan.

Age:  Pellagra is typically a disease that affects adults.  Adolescents and young children who follow pellagragenic diet can develop pellagra.  Pellagra very rarely affects the infants.

What are the different stages?

Early findings:  In the first stage, acute pellagra resembles a sunburn.  The skin becomes red, blebs or blisters develop and leave loss of surface areas which resemble a severe sunburn.  The eruption usually begins as acute dermatitis accompanied by edema and then change to erythema (redness of the skin) on the upper surface of the hands, with pruritus and burning.  Initial bright erythema may change to cinnamon brown in color. Blisters evolve after several days from the onset of erythema.

The blisters may combine into bullae and then break. In other patients, dry brown scales and blackish crusts, resulting from hemorrhage, form after 2 to 4 weeks.  The skin area which is exposed to sunlight and heat or if there is friction or pressure applied, it causes redness and superficial scaling.

Late findings:  During the second stage, the skin becomes hard, rough, cracked, and brittle.  Patients have thickened skin that is dry, scaly, and hyperkeratotic with a parchment-like appearance and a yellowish brown hue.  The skin is darkly pigmented and during extreme cases of deficiency, the skin becomes harder, drier, more cracked, and covered with scales.  Blisters are present when pellagra recurs at the same site and they contain lymphocytes, segmented leukocytes, and histiocytes and occasionally, pustules, crusts, and deep fissures are present.

Pellagra can affect…

Pellagra can affect any part of the body surface, but it more frequently appears in certain areas and the usual sites are the dorsal surfaces of the hands, face, neck, arms, and feet.

Hands:  The backs of the hands are the most common sites for the lesions, which accounts for 77% to 97% of cases.  Lesions spread to the arm representing a glove. The outer surface of the skin of the fingers thicken and the folds vanish.  Painful fissures develop on the palms and digits.

Face:  Skin rash spreads along with the distribution of the trigeminal nerve, and the skin appears to be pigmented with a pattern of butterfly eruption and also looks similar to lupus erythematosus in appearance.  A characteristic well-marginated eruption appears on the front of the neck and is called a Casal necklace as compared with scales elsewhere. Scales that are formed on the face become fat and in some cases becomes pustular.  Lesions spread from the sides to the rest of the nose, forehead, cheeks, chin, lips, and rarely to the eyelids and ears.

Neck:  The Casal necklace spreads in a broader way and surrounds the entire neck.  The upper border of the Casal necklace extends anteriorly whereas the lower border of the Casal necklace begins under the vertebral column.  The Casal necklace extends up to the level of the sternum and even the nipples. On the back, the affected border may extend up to the scapulae.

Feet:  Lesions usually do not extend proximally to the malleoli, which are included and may be covered with hyperkeratotic erythema.  The heels remain free of lesions. The front and back portions of the feet gets involved to form a boot pattern. On the palms and soles, skin appears yellowish, dry, rough, and scaly.  In children, erythematous lesions appear on the palms and soles.

Other areas such as shoulders, forearms, elbows, and knees are also affected.

Nails:  Nails are soft, crumbly, and dull.

Eyes:  Keratoconjunctivitis and keratomalacia may occur.

The mucosal surface of the GI tract:  In one-third of patients affects by pellagra, the lips, tongue, and oral mucous membranes are involved.  The tongue first becomes hypertrophic (increases in volume), with furs, ulcers, and erosions, and later the tongue becomes atrophic.  

Other clinical findings include cheilosis (painful inflammation and cracking of the corners of the mouth), angular stomatitis (a condition that causes red, swollen patches in the corners of the mouth), and thrush (a fungal infection caused by the species called as Candida on the skin or mucous membranes).  Bleeding from the gingiva occurs without hemorrhages.  The lips are inflamed, rough, achy, and shiny.

Gastrointestinal tract:  The main symptoms include poor appetite, nausea and vomiting, stomach discomfort, abdominal pain, and increased salivation, which affects around 50% of the patients affected by pellagra.  Glossitis is a medical condition which affects the mouth causing soreness of the mouth as well as dysphagia. Diarrhea occurs due to the involvement of the mucosal surface of the gastrointestinal tract where the stools are watery, but can sometimes become bloody and mucoid.

Neuropsychiatric manifestations:  Neuropsychiatric manifestations include a headache, irritability, poor concentration, anxiety, delusions, hallucinations, stupor, apathy, psychomotor unrest, photophobia, tremor, ataxia, spastic paresis, fatigue, and depression.  

These symptoms may advance to encephalopathy and may cause confusion, psychosis, or memory loss. As the pellagra disease advances, patients tend to have symptoms of disorientation and confusion and finally, patients become stuporous and comatose and die.

Diagnosis

The typical symptoms and signs of pellagra indicate the diagnosis and subsequently, diagnosis is confirmed with blood counts, hypoproteinemia, higher levels of serum calcium, liver function test results, and serum porphyrin levels.  Low urinary levels of N- methylnicotinamide and pyridone suggest niacin deficiency and hence the diagnosis of pellagra can be confirmed.

What is the prognosis?

The morbidity of pellagra depends on the organs that get involved during the disease process.  Dermatitis caused by pellagra generally is painful with burning during the severe stages.  Systemic conditions such as malaise, weakness, and lassitude can affect the daily lifestyle. Stomach involvement such as malabsorption and diarrhea leads to failure to thrive.  Neurologic conditions which are caused due to the disease condition such as anxiety, depression, delusions, and hallucinations may affect the patient very heavily. The prognosis for pellagra is excellent when the disease is diagnosed and treated appropriately.

Treatment of pellagra

Oral therapy which includes nicotinamide or niacin is very useful in eradicating and reversing the symptoms of pellagra.  Since malnourishment and lack of protein diet cause the disease, it is very important to administer these nutrients for complete recovery.  Patients affected with pellagra, unfortunately, do not have the ability to carry out the daily chores and will require bed rest and consume a liquid or a soft solid diet to combat dysphagia.  It is very important to ensure that the patient has a balanced diet that is rich in protein and niacin. Topical emollients help in reducing the discomfort of dermatitis and help towards the road to recovery.

Diet 

The diet of a patient affected by pellagra needs to include a protein-rich diet with adequate calories.  A combination of food products such as adding meats, milk, peanuts, leafy green vegetables, grains, and brewer’s dry yeast is a  source of niacin and help in preventing as well as treating pellagra.  Since the patients suffer from dysphagia caused by glossitis, a liquid or a semisolid diet is advisable. Milk, meat, and eggs provide an protein-rich diet and the required amount of proteins essential for absorbing the nutrients.

Prevention 

Primary prevention is as follows:

  • Consuming a diet, which is rich in niacin and/or tryptophan should be considered and some of the examples of include eggs, bran, nutritional yeast, peanuts, meat, poultry, fish, red meat, cereals, legumes, and seeds.
  • The recommended amount of niacin required daily for infants is 5 mg to 6 mg.  For children 9 mg to 13 mg. For adults 13 mg to 20 mg. 17 mg for pregnant women and for breastfeeding women 20 mg.

Secondary prevention is as follows:

  • Patients affected by pellagra should prevent exposing the skin to sunning-the active phase of pellagra disease.
  • Patients should follow the advised dietary regimen given to them by their doctor.
  • Following a similar diet as recommended during the patient’s recovery will prevent the recurrence of pellagra.

 

Dos and Don'ts

Dos
  • Consume a diet rich in niacin and/or tryptophan.
  • Include protein rich foods
  • Use sunscreen while going outdoors.
  • Apply moisturizer to affected skin at least once a day.
  • Stay hydrated.
Don'ts
  • Consume foods that lack nutrition.
  • Expose your skin to sun.
  • Increase corn-based foods in the diet.
  • Drink alcohol.
  • Depend on unapproved drugs for treatment

 

 

 

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Diverticulitis diet: The right way to eat if you suffer from the disease Are you suffering from diverticultis but clueless about your diet ? Read this complete plan for diverticulitis diet…
folate test
Folate test The Folate test measures and monitors the levels of folic acid in the blood. This test is also…
lipoprotein A
Lipoprotein (A) Test Lipoprotein (A) test is used to measure and monitor the levels of LDL(Low-Density Lipoprotein) in the bloodstream in…
AUTOIMMUNE HEPATITIS liver
Hepatitis Profile A hepatitis profile or a hepatitis panel is a blood test that checks for markers of hepatitis infection…
Hysteroscopy_procedure
Hysteroscopy Hysteroscopy is a minimally invasive tool to help specialists view the uterus to diagnose and even treat several…
sodium blood test
Blood Sodium Test A blood sodium test measures the amount of sodium (an important electrolyte) in your body. It is also…
urinary microalbumin test
Urinary Microalbumin Test The urine microalbumin test is a urine test that measures the level of microalbumin or protein in the…
CEA_test
Carcinoembryonic antigen (CEA) test CEA or carcinoembryonic test detects the presence of CEA antigen in your blood mainly & determines the effectiveness…
Triglycerides: The most effective steps in bringing the levels down What are trigylcerides ? And how can they lead to the onset of several chronic diseases, many of…
carrageenan seaweed
Carrageenan: How a simple seaweed extract could better your gut health & immunity Eat more ice cream to prevent cold and flu? –With carrageenan you get one simple seaweed extract that…
Rubella IgM test
Rubella IgM Test The Rubella IgM test is a blood test that is performed to diagnose the presence of the rubella…
dandelion weight loss
Caralluma Fimbriata: How to eat this cactus to lose weight Caralluma fimbriata is a miracle cactus that can be safely consumed by most for losing weight and boosting…
Pumpkin Seeds: Why pumpkins are more than just for pies! Pumpkins have been long associated with Halloween carvings and delicious pies. But did you know that pumpkin seeds…
Cordyceps: How the Caterpillar fungus works as a proven cancer-shield Strange as it may sound, but cordyceps or "caterpillar fungus", a fungus variety native to the Himalayas may…
green poop causes
Green poop : What are the reasons and how can you correct it Ever sneak a peek down the toilet only to shockingly find green poop? Why does our poop turn…
complement c4 test
Anemia Profile Anemia Profile test (Basic) is a blood screening test that measures the levels of important components of the…
apolipoprotein a1 test
Apolipoprotein -A1 (APO-A1) Test Apolipoprotein A-I (Apo-A1) constitutes 70% of protein content in high-density lipoprotein (HDL) and helps in lipid metabolism.
aspartame or sugar
Aspartame – Hidden truths about this storm in a teacup Aspartame, the artificial sweetener, has gone under the scanner on several occasions for allegedly doing more harm than…
Juice Plus: Can you really replace actual fruits with pills?  Juice Plus supplements intend to fill nutritional gaps present in our daily diet. But how successful have they…
Diabetes blood test
Diabetic Profile The diabetic profile is a set of tests used for testing and monitoring the various kinds of Diabetes…
Jack in the box fast food
Jack In the Box : The perils of surging fast food culture in the USA Jack in the Box - How a culture of fast-food can clog your arteries, weaken your heart, fatten…
Love tea, hate tannins? Rooibos tea is just what you need The market is brimming with a multitude of herbal teas. But what makes rooibos tea (or red bush)…
Is bronchitis contagious? And how to prevent this infection? It is acute bronchitis that is contagious which means you can contract it from another person or you…
cytomegalovirus iGG
Cytomegalovirus (CMV)- IgG Test The cytomegalovirus IgG is the immunoglobulin protein produced by our immune system when the body is infected by…
woman with abdominal pain holding ovulation calendar
Ovulation – facts to know about ovulation Learn how and when ovulation occurs, demystify common misconceptions, identify symptoms, methods of detection and right period for…
phenytoin test
Phenytoin test Phenytoin is a drug that is administered mainly to epilepsy patients. The phenytoin blood test measures the level…
Tissue Transglutaminase Antibody (tTG) Test Transglutaminase is an enzyme present in our body and is involved in protein metabolism. A tTg test is…
Chlorella: Therapeutic powers of the billion-year-old algae now within your reach Chlorella - A billion year old nutrient-rich algae that can potentially ward off cancers and high cholesterol; the…
Okra: How can this nutrient-dense vegetable help you fight diabetes? Okra is a food which is rich in nutrients and minerals which are extremely essential for a healthy…
tonometry
Tonometry Tonometry uses a device called tonometer to measure the pressure inside the eye. This pressure is depends upon…
fructosamine test
Fructosamine Test A fructosamine test measures blood sugar glucose content. Fructosamine level can indicate blood sugar level in past 2-3…
dhea adrenal
Androstenedione Test Androstenedione is produced by the adrenal gland, the test of the levels of Androstenedione helps in the evaluation…
GM Diet: The fastest way to lose weight or yet another hoax diet? General Motors started this trend of extreme dieting for 7 straight days to ensure its employees were able…
How can Kegels help you overcome weak pelvic muscles & incontinence? Kegel exercises are pelvic floor strengthening exercises that can help you overcome incontinence issues that rise out of…
rosacea-treatment--before-_-after
The best and safest ways to treat rosacea Rosacea is a skin disease that is characterized by reddish hives and rashes on the face. Read more…
about mediterranean diet
Why you should be adopting a Mediterranean style of diet today Ever wondered why the Mediterranean diet is so healthy? One simple solution to lowering risk of several deadliest…
CERULOPLASMIN- triple marker
Triple Marker Test A triple marker test is an important prenatal test that is performed to detect the presence of chromosomal…
working mom with kids
Practical Motherhood Tips for Working Women Check out these effective tips for working mothers to manage motherhood and work life. Raise your children easily…
kidney stones
Kidney stones Kidney stones are solid substances made up of crystals. They can be of various sizes. Treatment depend on…
Dragon Fruit – Blessing from Nature’s Basket Dragon fruit is packed with nutrients but low on calories. It is the dream food that can help…
Bubble Tea: Bubbling with nutrition or a hidden sugar mine? The tapioca pearls present in the tea looks like bubbles and hence the name bubble tea became popular.…
shakeology woman
Meal replacement or protein drink? Learn all about Shakeology and its claims Shakeology from Beachbody claims to be the most suitable shake that can aid in weight loss, regulate blood…
BRAT Diet: What is the right way to follow this diarrhea-relieving diet? BRAT diet, a simple diet consisting of just bananas, rice, applesauce, and toast, can help you combat the…

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Welcome to your Nutrient Deficiency Quiz

What type of sun rays help synthesize vitamin D?
Which disorder is characterized by inability to speak in certain social situations?
Beriberi is caused by the lack of this micronutrient-
Can stuttering be genetic?
Which of these vitamins are needed for calcium absorption by the body?
What is scoliosis?
People with darker skin are more prone to vitamin D deficiency.
If you have thiamine deficiency, which of these should you avoid consuming with your thiamine rich diet?
Which of the following is a speech disorder that affects the pronunciation of letters like s, z, r?
Consumption of mushrooms exposed to UVB rays help with low vitamin D levels.

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