Pellagra is a disease caused by a lack of the vitamin niacin (vitamin B3). Symptoms include inflamed skin, diarrhea, dementia, and sores in the mouth. Areas of the skin exposed to friction and radiation are typically affected first. Over time, affected skin may become darker, stiffen, peel, or bleed. The two main types of pellagra are primary and secondary. Primary pellagra is due to a diet that does not contain enough niacin and tryptophan. Secondary pellagra is due to a poor ability to use the niacin within the diet. This can occur as a result of alcoholism, long-term diarrhea, carcinoid syndrome, Hartnup disease, and a number of medications such as isoniazid. Diagnosis is typically based on symptoms and may be assisted by urine testing. Treatment is with either nicotinic acid or nicotinamide supplementation. Improvements typically begin within a few days. General improvements in diet are also frequently recommended. Decreasing sun exposure via sunscreen and proper clothing is important while the skin heals. Without treatment, death may occur. The disease occurs most commonly in the developing world, often as a disease of poverty associated with malnutrition, specifically sub-Saharan Africa.
Etymology The word "pellagra" is known to come from Lombardic, but its exact origins are disputed. "Pell" certainly arises from classical Latin pellis, meaning "skin". "-agra" may arise from Lombardic agra, meaning "like serum or holly juice", or the Latinate -agra, a suffix for maladies itself borrowed from the Greek ἄγρα, meaning "a catch-point, a hunting trap".
Signs and symptoms
The classic symptoms of pellagra are diarrhea, dermatitis, dementia, and death (the four Ds). A more comprehensive list of symptoms includes:
Dermatitis (characteristic "broad collar" rash known as casal collar) Hair loss Swelling Smooth, beefy red glossitis (tongue inflammation) Trouble sleeping Weakness Mental confusion or aggression Ataxia (lack of coordination), paralysis of extremities, peripheral neuritis (nerve damage) Diarrhea Dilated cardiomyopathy (enlarged, weakened heart) Sensitivity to radiation Eventually dementia J. Frostigs and Tom Spies—according to Cleary and Cleary—described more specific psychological symptoms of pellagra as:
Psychosensory disturbances (impressions as being painful, annoying bright lights, odors intolerance causing nausea and vomiting, dizziness after sudden movements), Psychomotor disturbances (restlessness, tense and a desire to quarrel, increased preparedness for motor action), as well as Emotional disturbances Independently of clinical symptoms, blood level of tryptophan or urinary metabolites such as 2-pyridone/N-methylnicotinamide ratio less than two or NAD/NADP ratio in red blood cells can diagnose pellagra. The diagnosis is confirmed by rapid improvements in symptoms after doses of nicotinamide (250–500 mg/day) or nicotinamide-enriched food.
Pathophysiology Pellagra can develop according to several mechanisms, classically as a result of niacin (vitamin B3) deficiency, which results in decreased nicotinamide adenine dinucleotide (NAD). Since NAD and its phosphorylated NADP form are cofactors required in many body processes, the pathological impact of pellagra is broad and results in death if not treated. The first mechanism is simple dietary lack of niacin. Second, it may result from deficiency of tryptophan, an essential amino acid found in meat, poultry, fish, eggs, and peanuts, which the body uses to make niacin. Third, it may be caused by excess leucine, as it inhibits quinolinate phosphoribosyl transferase (QPRT) and inhibits the formation of nicotinic acid to nicotinamide mononucleotide (NMN) causing pellagra-like symptoms to occur. Some conditions can prevent the absorption of dietary niacin or tryptophan and lead to pellagra. Inflammation of the jejunum or ileum can prevent nutrient absorption, leading to pellagra, and this can in turn be caused by Crohn's disease. Gastroenterostomy can also cause pellagra. Chronic alcoholism can also cause poor absorption, which combined with a diet already low in niacin and tryptophan produces pellagra. Hartnup disease is a genetic disorder that reduces tryptophan absorption, leading to pellagra. Alterations in protein metabolism may also produce pellagra-like symptoms. An example is carcinoid syndrome, a disease in which neuroendocrine tumors along the gastrointestinal tract use tryptophan as the source for serotonin production, which limits the available tryptophan for niacin synthesis. In normal patients, only 1% of dietary tryptophan is converted to serotonin, but in patients with carcinoid syndrome, this value may increase to 70%. Carcinoid syndrome thus may produce niacin deficiency and clinical manifestations of pellagra. Antituberculosis medication tends to bind to vitamin B6 and reduce niacin synthesis, since B6 (pyridoxine) is a required cofactor in the tryptophan-to-niacin reaction. Several therapeutic drugs can provoke pellagra. These include the antibiotics isoniazid, which decreases available B6 by binding to it and making it inactive, so it cannot be used in niacin synthesis, and chloramphenicol; the anticancer agent fluorouracil; and the immunosuppressant mercaptopurine.
Treatment If untreated, pellagra can kill within four or five years. Treatment is with nicotinamide, which has the same vitamin function as nicotinic acid and a similar chemical structure, but has lower toxicity. The frequency and amount of nicotinamide administered depends on the degree to which the condition has progressed.
Epidemiology
… excerpt ends here. Continue reading the full article.
