Pellagra (Niacin deficiency)

Notes

## Basic introduction

  • Pellagra is a disease that is caused by a chronic lack of niacin (vitamin B3) in the diet.
  • There have been increasing cases of pellagra among prisoners in Kenya.
  • The most common biologically active derivatives of niacin are nicotinic acid and nicotinamide.

## Causes of pellagra

  • Dietary deficiency arising from starvation, defective absorption and utilization of niacin, and alcoholism
  • Diets based on corn as staple food (low in tryptophan and niacin)
  • Liver cirrhosis
  • Isoniazid therapy
  • Eating disorders such as anorexia nervosa
  • Some diarrheal diseases
  • Carcinoid syndrome (where tryptophan is substantially converted to serotonin)
  • Malabsorption of tryptophan e.g. in Hartnup's disease
  • Dehulling of maize before consumption (e.g. "Muthokoi" among the Kamba community in Kenya) leads to its deficiency in niacin.

## Sources of niacin

  • Beans
  • Milk
  • Eggs
  • The liver also synthesizes niacin from tryptophan, where 60mg of tryptophan are required to make 1mg of niacin.

## Pathogenesis of pellagra

  • Nicotinic acid and nicotinamide are precursors of nicotinamide adenine dinucleotide (NAD) and nicotinamide adenine dinucleotide phosphate (NADP).
  • The two co-enzymes are required in important oxidative and reductive reactions such as synthesis of steroid and fatty acid synthesis, among others.

##Statistics

  • Dietary pellagra minimally present in the developed countries but it still present in the tropical countries.
  • The prevalence of pellagra in various countries are as follow: Zimbabwe (1.5%), Malawi (0.2 - 2.0%), Mozambique (1.4) and 3.15% in Kathiani Division (Kenya)
Symptoms

## Classical symptoms and signs (3 Ds’)

  • Dementia
  • Diarrhea
  • Dermatitis

## Other symptoms and signs

  • Generalized weakness
  • Abdominal pain
  • Anorexia
  • Bright red glossitis
  • Dermatitis
  • Dysphagia
  • Irritability
  • Oesophagitis
  • Paranoid psychosis
  • Paraesthesia
  • Skin lesions that are mostly found on the exposed parts of the body: face, neck, hands and feet
  • Scarlet stomatitis
  • Vaginitis
  • Vomiting
  • Weight loss
Diagnosis
  • Clinical review
Differential
  • Contact dermatitis
  • Deficiency of other nutrients and vitamins
  • Drug Eruptions
  • Drug-Induced Lupus Erythematosus, and Pemphigus
  • Eczema
  • Kwashiorkor
  • Pemphigus Vulgaris
  • Porphyria Cutanea Tarda
  • Hartnup Disease
  • Pediatric Atopic Dermatitis
  • Polymorphous Light Eruption
  • Seborrheic Dermatitis
  • Subacute Cutaneous Lupus Erythematosus
Prevention
  • Balanced diet
  • Fortification of maize flour
Reference
  1. Jacobson, EL (2007). "Niacin". Linus Pauling Institute. Retrieved 10 January 2017
  2. Kenyan Ministry of Health. Clinical guidelines for management and referral of common conditions at levels 4-6. Hospitals. 2009; 3:259-261.http://apps.who.int/medicinedocs/documents/s21000en/s21000en.pdf
  3. Ministry of Health, Kenya. Kenya Essential Medicine List (2016). http://publications.universalhealth2030.org/uploads/KEML-2016Final-1.pdf
  4. Ng’ang’a HN. Dietary practices and prevalence of pellagra in Kathiani division of Machakos district. MSc Thesis, 2010, University of Nairbi
  5. Prousky JE; Pellagra may be a rare secondary complication of anorexia nervosa: a systematic review of the literature. Altern Med Rev.2003 May;8(2):180-5
  6. World Health Organization: Pellagra and its prevention and control in major emergencies. http://whqlibdoc.who.int/hq/2000/who_nhd_00.10.pdf on March 7, 2012
Management
  • High protein diet
  • Multivitamins
  • Tabs Nicotinamide 100-200mg TID until the symptoms disappear.
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