1. PELLAGRA

2. INTRODUCTION
• Ita : Pelle – Skin ; Agra – Sour
• 1755 Françoise Thiery Vulgo Pelagrain
• 1762 – Gasper Casal in Oviedo, Asturias ; poor peasants –
Mal de la rose
• 1771 - Francesco Frapolli - ‘PELLAGRA’
• 1902
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American epidemic
• Goldberger (1926) – Nutritional correction reversal

3. DEFINITION
• Cellular deficiency of niacin, resulting from an
inadequate dietary supply of Niacin (Vit B3 /
Vit PP / Nicotinic Acid) and tryptophan, or
high Leucine, is termed Pellagra
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4. ETIOLOGY
PRIMARY / DIETARY
Corn / Maize-diets (Bound Niacin)
Jowar (High Leucine content)
Uncommon in Mexicans (Nixtamalization)
GI DISEASE
Jejuno-Ileitis / Prolonged Diarrhoea / IBD
MALABSORPTION SYNDROME
CARCINOID SYNDROME

5. HARTNUP DISEASE
• Brush-border system defect
• Defective transport / absorption of AAs
CHRONIC ALCOHOLISM
ANOREXIA NERVOSA
FOOD FADISM
FOOD ALLERGIES

6. DRUGS
ISONIAZID
FLUOROURACIL
6-MP
PHENYTOIN
AZATHIOPRINE
SULFONAMIDES
ANTIDEPRESSANTS
? HIV

7. PATHOGENESIS
• Component of Co-I (NAD) & Co-II (NADP) that
donate or accept H+ in Carbohydrate / Fat /
Protein Metab
• Downregulates pro- inflamm CKs (IL-1,6,8,12 /
TNF-A)
• Produces Ceramides / Corneal Lipids –
maintain Epithelial Permeability, Decrease
Basal Cell Proliferation

8. CLINICAL FEATURES
• 04 Ds
Dermatitis
Diarrhoea
Dementia
Death (due to MODS)

9. CUTANEOUS MANIFESTATIONS
• Erythematous, Pruritic, Painful Photosensitive
dermatitis
• Edematous, Vesiculobullous lesions
• Hyperkeratotic, hyperpigmented, sharply
demarcated plaques
• Painful fissured palms, soles with goose-flesh

11. • aaa

12. • Butterfly Rash over face

13. • Dorsum of Hands affected – Radial > Ulnar
GAUNTLET SIGN

14. • Upper - portion of Neck and Chest
CASAL’S NECKLACE with Sternal CRAVAT

15. MUCOSAL INVOLVEMENT
ANGULAR STOMATITIS
GLOSSITIS
CHEILITIS
ULCERATIONS (BUCCAL / VULVAL)

16. GI MANIFESTATIONS
• Precedence
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Nausea / Vomiting
Anorexia
Diarrhoea
Pain Abdo

17. NEUROLOGICAL INVOLVEMENT
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Insomnia
Fatigue
Nervousness
Apathy
Impaired Memory
Depression
Psychosis
Dementia

18. DDx
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PMLE
ATOPIC DERMATITIS
DRUG RASH
SCLE
PCT
KAVA DERMOPATHY (Piper Methysticus)
SEBORRHEIC DERMATITIS
CONTACT DERMATITIS
HYDROA VACCINIFORME
PHYTOPHOTODERMATITIS
ACTINIC LP

19. DIAGNOSIS
• CLINICAL
• THERAPEUTIC
• Lab estimation of N-Methyl Nicotinamide
• HPE

20. HISTOPATHOLOGY
• HYPERKERATOSIS – PARAKERATOSIS
• ACANTHOSIS
• BALLOONING OF KERATINOCYTES /
SCATTERED NECROTIC CELLS
• DILATED BLOOD VESSELS
• MINIMAL INFLAMM INFILTRATE

21. • SS

22. TREATMENT (DIETARY)
• TRYPTOPHAN-RICH FOODS viz Liver / Eggs / Legumes / Nuts
• RDA (NIACIN)
Males: 19-50 years : 19 mg/day; >50 years : 15 mg/day
Females: 19-50 years : 15 mg/day; >50 years : 13 mg/day
Pregnant: 18 mg/day
Nursing: 17 mg/day
• NIXTAMALIZED MAIZE (CURED CORN)
• AVOIDANCE OF JOWAR

23. TREATMENT (MEDICAL)
• NICOTINAMIDE
500mg / day X 03-04 weeks
Neurological reversal within 24-48 hrs
Cutaneous resolution within 04 weeks
• NIACIN
50-100mg PO TDS X 03-04 weeks
• TREATING UNDERLYING CAUSES IN SECONDARY
PELLAGRA

24. THANK YOU