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. Keywords: Crohn's disease; Niacin; Niacinamide; Pellagra Pellagra was first described in 1735 by the Spanish physician Gaspar Casal. Chronic alcoholism can be a main cause of pellagra in some developed countries.1 In developing countries, the disease may be increasing among HIV-positive patients. Other causes include carcinoid syndrome, Hartnup disease, infection, and isoniazid or fluorouracil therapy. We report here a case of pellagra affecting aCrohn's disease (CD) patient, which is rarely reported in China.A 49-year-old woman with CD was admitted to our hospital with abdominal pain, diarrhea and a temperature of 38°C in 2014.She had been diagnosed with CD for three years and was treated with mesalazine and prednisone. In 2012, a lower enteroscopy showed fistulas arising from the transverse colon, ileum and descending duodenum. In April 2013, the disease flared for the second time and infliximab was administered for 3 times with unsatisfactory results. After that, the patient followed a very strict diet that was basically limited to pasta, avoiding red meat, fish, milk, and eggs while continuing the treatment with mesalazine. On admission, the patient had normal weight and normal blood pressure with temperature of 37.6°C. Physical examination only revealed the surgery scars and skin change without itches or pain. Dark-brown coloration and scaly desquamation of the skin were noticed on the neck, dorsum of the hands, and ankles, which would aggravate after sun exposure (Figure 1). The neck and ankles were tender.Laboratory test results at admission were as follows: he- Pellagra is rarely reported as a complication of CD caused by a deficiency of niacin. 2 The prevalence of the disease might be misleading due to underdiagnosis.

Isoniazid‐induced pellagra in a patient with Crohn's disease

“…CD is associated with decreased absorption of niacin and seems to have a role in developing this nutritional disorder. A review of the literature confirms the paucity of reports of pellagra as a complication of CD . The three “Ds” of pellagra were observed in our patient, and this association is present in only 22% of patients .…”

“…NAD and NADP participate in numerous processes including amino acid metabolism and the generation of high‐energy phosphate bonds. This would explain why pellagra mainly affects fast‐renewal tissues such as skin and the digestive tract, and tissues with high‐energy needs, such as the brain neurons …”

Dermatological Manifestations in Pediatric Inflammatory Bowel Disease

“…In developed countries, pellagra is rarely reported, and physicians may be tempted to overlook this diagnosis or to associate it only with poor socio-economic status. Pellagra is characterized by the three “D’s” triad: dermatitis, diarrhea, and dementia; left untreated, death, the fourth “D”, may appear [ 74 ]. Cutaneous manifestations include erythematous desquamating rash with surrounding hyperpigmentation [ 75 ].…”

Chronic Diarrhea in a Drinker: A Breakthrough Case of Pellagra in the US South

“…The early clinical diagnosis in our case conferred a good prognosis, and cases reported within the past 5 years have resolved with treatment ( Table 1 ). 18 - 24 Though considered by many as a disease of the past, clinicians should still maintain a high index of suspicion for pellagra as differential diagnosis for delirium or dementia in alcoholics, which may occur with or without dermatologic or GI manifestations.…”