1848 Chronic Diarrhea Complicated by Hyponatremia as a First Clue to Establish the Diagnosis of Pellagra

Abstract

INTRODUCTION: We report a case of middle age man with a history of chronic alcohol abuse, who presented with chronic diarrhea for a month resulted in moderate to severe hyponatremia and was diagnosed with a rare in Western World disease of Pellagra. CASE DESCRIPTION/METHODS: This is a relatively young man 49yo with long history of alcohol abuse, who presented with mainly GI symptoms of nausea, non bloody vomiting, watery diarrhea for a month, abdominal pain, and leg rash. Blood work was significant for hyponatremia (121), thrombocytopenia (133), and alcohol level of 87.5. The physical exam was significant for erythematous, dry rash with areas of desquamation on both legs, associated with pruritus and LLQ tenderness. He was evaluated by MICU team, treated for moderate to severe hyponatremia in ER with IV fluids and admitted to medical floor for chronic diarrhea and LE rash workup. Patient has been evaluated by dermatology and Pellagra with other nutritional deficiencies vs Tinea was suspected. He underwent a punch biopsy and started on niacin as well as urea 40% cream. Pathology was consistent with nutritional deficiencies (i.e. zinc, niacin). After careful compilation of all parts of history, physical exam, and pathology, patient was diagnosed with Pellagra and continued on niacin supplementation with resolution of diarrhea and improvement of skin appearance. DISCUSSION: Pellagra is a nutritional disorder that results from inadequate intake of niacin or its precursor, the essential amino acid tryptophan. Pellagra is a disease very nearly eradicated in US and Europe except sporadic cases in at-risk groups (chronic alcoholism, malnutrition, malabsorption. It is classically described by the 3 D’s “diarrhea, dermatitis, and dementia”. While the life threatening presentation of Pellagra is very uncommon nowadays, the most severe cases are usually presented as encephalopathy. In our case patient presented with chronic diarrhea, which caused almost life threatening hyponatremia. Diarrhea as the first presenting symptom along with characteristic rash and history of chronic alcohol leaded to diagnosis of Pellagra, the disease easily treated with prompt administration on niacin. Pellagra is mostly a clinical diagnosis and careful collection of all parts of history and physical exam required to early recognize the disease and initiate a niacin intake. Physicians should have a high index of suspicion in certain groups of patients to early diagnose and cure this potentially fatal but treatable disease.