Gastrointestinal: Life‐threatening diarrhea due to pellagra in an elderly patient

Abstract

Female patient, 61 years-old, heavy smoker, and heavy drinker, sought care because of watery diarrhea, severe weight loss (around 40 pounds), alteration of mental state, and skin rash. She presented with signs of dementia (blurry speech, mental confusion, and amnesia) and severe malnutrition. Initial investigation had shown anemia (hemoglobin = 8.5 g/dL), low albumin (2.05 g/dL), and an increase of liver enzymes (GGT = 450 U/L and alkaline phosphatase = 287 U/L). Serological tests for syphilis, HIV, hepatitis C virus, and hepatitis B virus were negative. Parasitological stool examination and fecal leukocyte tests were normal, anti-transglutaminase IgA and IgG antibodies were negative, and she had a normal oral lactose tolerance test. Colonoscopy was performed, showing normal mucosa with a normal anatomopathological study of colon biopsies. The skin rash, tough, was very relevant for the case: hyperpigmentation, scaling, and skin thickening on the face, upper chest, and upper and lower limbs-areas exposed to sunlight (Figs. 1, 2). A presumptive diagnosis of pellagra was made by the clinical gastroenterology team. Supplementation of nicotinamide in the dose of 50 mg QID was began and maintained for 28 days, with resolution of diarrhea and of the skin rash, a substantial weight gain, and a considerable improvement of mental status. Because in Brazil there is no commercial nicotinamide presentation, it was used 20 daily tablets of complex B vitamins, which contain 10 mg of nicotinamide each. The patient was discharged with maintenance supplementation of complex B vitamins and a plan for treatment of alcoholism. Pellagra is a disease caused by the deficiency of niacin (vitamin B3), first described in 1735 by the Spanish physician Gaspar

Duodenal Crohn’s disease: Case report and systematic review

“…It is paramount to consider many differentials when DCD is suspected. For example, celiac disease[ 103 , 104 ], enteric neoplasms and metastasis[ 105 , 106 ], foreign body ingestion[ 107 ], pellagra[ 108 ], enteric infections[ 109 - 111 ], sprue-like enteropathy associated with the angiotensin II receptor blocker[ 112 ], extra-intestinal manifestations[ 113 ] and hemophagocytic lymphohistiocytosis[ 114 , 115 ].…”