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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Iron Deficiency Profile An iron deficiency profile is a battery of blood tests which are performed in order to determine the…
immunoglobulin M
Immunoglobulin M Test Immunoglobulin M is the largest and the first produced antibody which helps in the prevention or fighting of…
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…
Coconut sugar: What is it and is it healthier than table sugar? In the long list of things that the wonderful coconut gives us, coconut sugar is another remarkable addition.…
The Cabbage Soup Diet: The healthiest way to instant weight loss Cabbage soup diet rapid weight loss diet for those who want to shed those extra pounds in less…
Sputum test Sputum test is a commonly used diagnostic tool that is used to examine the presence of pathogens in…
Helicobacter pylori IGA
Helicobacter Pylori – IgA Test The H.pylori IgA test is a blood test used to identify the level of IgA antigen in the…
17 OH Progesterone test The 17 OH progesterone test is a simple blood test that is mainly used to diagnose the cause…
vital organ diseases
Common diseases that could cripple your vital organs Brain, heart, kidney, lungs, and liver - these vital organs are indeed vital for your survival. However, these…
black seed oil benefits
Black Seed Oil: What secret benefits could it bestow on your health? Black seeds or nigella seeds are tiny packets of health brimming with amazing benefits. Find out why should…
Cottage cheese: What can you find in this healthy chunk of fresh milk cheese? Love cheese but scared of putting on extra pounds? With cottage cheese, you can get the best of…
What is the right way to take a pregnancy test? A pregnancy test is undertaken to determine if you have conceived. A home pregnancy test is the most…
11 unbelievable health benefits of thyme you didn’t know! Thyme is a herb that has been used in alternative medicine.It is a well known seasoning in the…
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Easy and safe tips for ear wax removal you can do at home Cerumen impaction generally occurs when an external object like cotton swabs are used to remove the ear wax.…
Inhale oxygen, exhale worries: The top breathing exercises and how to perform them Performing the breathing exercise is like becoming mindful of how you breathe.  Here is a list of breathing…
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5 things you didn’t know about balneotherapy and how you can do it at home Sauna baths have been popular since a long time. But how much more beneficial can balneotherapy be as…
tonometry
Tonometry Tonometry uses a device called tonometer to measure the pressure inside the eye. This pressure is depends upon…
Bloodtestalbumin
Albumin Test Albumin test or blood serum test is a liver function test that measures the amount of the protein…
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Hysteroscopy Hysteroscopy is a minimally invasive tool to help specialists view the uterus to diagnose and even treat several…
phenytoin test
Phenytoin test Phenytoin is a drug that is administered mainly to epilepsy patients. The phenytoin blood test measures the level…
Rubella IgM test
Rubella IgM Test The Rubella IgM test is a blood test that is performed to diagnose the presence of the rubella…
cystatin C
Cystatin C Test Cystatin C is a specific single-chain protein that is found in body fluids and is a biomarker for…
5 htp brain
5-htp: Is this the ultimate cure for those pesky migraines attacks? 5-htp is a supplement that is extracted from the plant Griffonia simplicifoli.  It is an amino acid that helps…
Bromelain: 11 reasons why you should start adding pineapple to your pizza! If you didn't love pineapples already, here are some of the top health benefits that bromelain can bring…
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…
Goji berry: A traditional Chinese berry that packs the best of antioxidants Goji berry is an ancient berry that is considered to be power-packed with nutrients and antioxidants. Which means…
How accurate is the hair follicle drug test? Hair follicle drug test is one of the best ways to identify drug use in professional circles. But…
sodium chloride
Halotherapy: How inhaling salt can work wonders for your body Halotherapy is quickly gaining popularity amongst those with respiratory diseases. It has shown promise in its treatment.
Quinine: How gin and tonic came to be known as a potent health elixir The discovery of quinine-containing tree bark is sometimes considered the most serendipitous medical discovery of the 17th century.
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CrossFit: Now get the perfectly sculpted body with this explosive gym routine CrossFit is a fitness regimen that makes use of high-intensity exercises in a shorter period to achieve muscle…
ASTtest-liver
AST- Aspartate Aminotransferase Test AST test is a blood test that is used to measure the level of a particular liver enzyme…
fructosamine test
Fructosamine Test A fructosamine test measures blood sugar glucose content. Fructosamine level can indicate blood sugar level in past 2-3…
leptospira Igm test
Leptospira-IgM Test A Leptospira-IgM test is a blood test which is carried out to detect anti-Leptospira IgM antibody. Leptospirosis is…
ureteroscopy
Ureteroscopy Ureteroscopy is the diagnostic procedure which is used for the detection of the kidney stones in addition to…
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…
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Ovulation – facts to know about ovulation Learn how and when ovulation occurs, demystify common misconceptions, identify symptoms, methods of detection and right period for…
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Hepatitis A Virus (HAV) Total Blood test to look for IgM antibodies to know if you are infected with Hepatitis A virus (HAV),…
liver detox facts
7 liver detox facts and why ignoring these could kill you! Are you taking care of this organ that handles over 500 different vital functions in your body? Your…
Tamarind: The top health benefits of this staple Asian ingredient Did you know this sweet and sour pulpy fruit does more than just add a tangy flavor to…
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Urologist: When should you visit one and why? A urologist can treat not only genitourinary problems of both men and women but also can treat various…
How to scrub away stress and fatigue with an Epsom salt bath? Epsom salt is a popular home remedy for many skin ailments. Though there is a lack of scientific…
SIBO Diet: The important dos and don’ts of this gut-healing diet A SIBO diet is a diet that works by eliminating certain sugars from your diet and adding fibers…
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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…
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Bronchoscopy procedure
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amylase test
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Period blood – what it says about your health Your period blood color and consistency indicate what is happening in your body. Is your blood bright red…
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Sweeteners – Are They Good or Bad for Our Health? Sweeteners can be artificial and natural. Learn about the different types of sweeteners and their health benefits and…
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avocado benefits
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Gout Diet : Get relief from painful joints by eating these foods Are you a victim of this painful condition? Are medications providing only short relief? Find a list of…
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Hydroxycut: How safe are these so-called weight loss supplements? Hydroxycut is a blend of several different ingredients formulated to promote weight loss; powered by a key weight…
Oil of Oregano: The one-stop essential oil you’ve been looking for Are you plagued by a weak immune system? High body inflammation accompanied by pain and infections? Why not…
Cayenne: The remarkable benefits of these red hot chili peppers These may make you rush for a glass of water, but cayenne pepper is actually a healthy additive…
The right way to prepare Alfalfa sprouts at home Alfalfa or lusan ghas is not just a nutritious animal fodder. This flavonoid-rich herb has some amazing health…
Did you know drinking alkaline water could be the healthier choice for you? Ever wondered how safe is your drinking water in terms of pH? Recent studies have revealed that Alkaline…
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)…
How seitan proved to be a blessing in disguise for vegans worldwide Can only meat-eaters enjoy delicious juicy steaks and burgers? With seitan, the best meat substitute available today,even vegans…
Pescatarian Diet 101: What are the inherent health advantages of this diet? People opt to become a pescatarian in order to enrich their bodies with the essential health benefits that…
GGt test
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blood elements analysis
Blood Element Analysis Test A blood element analysis is a blood test performed to measure the level of toxic elements such as…
folate test
Folate test The Folate test measures and monitors the levels of folic acid in the blood. This test is also…
lipase test
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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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