Pellagrous encephalopathy presenting as alcohol withdrawal delirium: A case series and literature review

Abstract

BackgroundAlcohol withdrawal delirium (AWD) is associated with significant morbidity and mortality. Pellagra (niacin deficiency) can be a cause of delirium during alcohol withdrawal that may often be overlooked.ObjectivesWe present a three-patient case series of pellagrous encephalopathy (delirium due to pellagra) presenting as AWD.MethodsWe provide a brief review of pellagra’s history, data on pellagra’s epidemiology, and discuss pellagra’s various manifestations, particularly as related to alcohol withdrawal. We conclude by providing a review of existing guidelines on the management of alcohol withdrawal, highlighting that they do not include pellagrous encephalopathy in the differential diagnosis for AWD.ResultsThough pellagra has been historically described as the triad of dementia, dermatitis, and diarrhea, it seldom presents with all three findings. The neurocognitive disturbance associated with pellagra is better characterized by delirium rather than dementia, and pellagra may present as an isolated delirium without any other aspects of the triad.DiscussionAlthough endemic pellagra is virtually eradicated in Western countries, it continues to present as pellagrous encephalopathy in patients with risk factors for malnutrition such as chronic alcohol intake, homelessness, or AIDS. It may often be mistaken for AWD. Whenever pellagra is suspected, treatment with oral nicotinamide (100 mg three times daily for 3–4 weeks) prior to laboratory confirmation is recommended as an inexpensive, safe, and potentially life-saving intervention.

Dyssebacia:An Early Cutaneous Marker of Niacin Deficiency

“…[4] In addition to skin changes, gastrointestinal involvement may lead to intractable diarrhea, stomatitis and glossitis, while the neurocognitive impairment pellagrous encephalopathy Stupor and death may result if pellagra is left untreated. [6,8] Fred HL [1] had reported one case of Dyssebacia, in this series we have discussed similar findings in 12 different patients of varying Age and Sex. The diagnosis of Dyssebacia is mainly clinical as there is scarcity of data in literature regarding Dyssebacia.…”

“…The characteristic skin rash has a typical photosensitive distribution with well defined borders forming the so-called Casal's necklace, the dorsa of the hands and the extensor surface of the forearms. [6] Bilateral symmetrical skin lesions over the bony prominences of the body sites include the knees, ankles, elbows and spinous processes. These lesions are hyperkeratotic and hyperpigmented.…”

Nicotinic acid and derivatives as multifunctional pharmacophores for medical applications

“…Pellagra is a severe nicotinic acid deficiency causing by an inadequate dietary intake of niacin or tryptophan [74,75]. Pellagra is clinically manifested as diarrhea, dermatitis, dementia, and Casal's necklace lesions on the neck.…”

Poverty Results In Madness: A Testimony from the Past

“…Currently, the disease is reported sporadically [25,26], in association with anorexia nervosa [27], chemotherapy and use of isoniazid [28] or chronic alcoholism [29]. In many parts of the world, however, the living conditions are similar to those of Polesine in the nineteenth century, perhaps even worse: in places where hunger is endemic, pellagra-like syndromes are highly probable.…”