pellagra

Every morning we check through the paper charts of the 20 men and 20 women inpatients looking for heart diseases to recruit.  In one of the smaller rooms of two, we read of a case of pellagra by alcoholism, a severe deficiency of niacin (Vitamin B3).  Pellagra is uncommon in the world today, since it only comes from very severe malnutrition, seen in some of the poorest third world or today from alcoholism or malabsorption from intestinal disease.  In the US, it was common in the South in the early 1900s, where the diet was mostly corn, but since the development of fortified food throughout the world, it is largely prevented.  It's classically learned as being a dementia, diarrhea, dermatitis, and eventually death if untreated.

So after we finished with patients at 4:30, we decided to check him out.  We walk in, spot an old disheveled man with spaghetti sauce all over his mouth and clothes, and hone in on him.  We manage to get his name, but cannot follow a single thing after that.  Makes sense that this be the alcoholic man with pellagra dementia.  We look to the other guy in the room, our age with blisters on both arms, and confirm with him that the old man is incomprehensible even to Spanish speakers.  The other man was 25 years old, who worked in garbage removal, and explained that he had an infection that spread and now covered both forearms.

Time for the charts.  Turns out the old man had tuberculosis meningitis (think high protein, low glucose in CSF) - don't worry parents this isn't at all as contagious as it sounds.  It was the young, relatable man who actually had fell to alcoholism, been brought in by a friend, and was being treated for pellagra dermatitis which was now superinfected.  On his extremely swollen feet, you could see clearly delineated blistering sun burns where his skin was exposed to the sun through his sandals (classic photosensitivity reaction).

After I asked to take a picture of his feet, he held out his bandaged
arms for another picture.  You can see the impressive line demarcating
where his neck was exposed to the sun, causing the rash and blisters 

This was almost a week after hiss
admission.  

Jackie and I were both chatting about how bizarre it was that this guy had such an extreme of malnutrition without other diseases first.  We were flipping through the labs, a quick task as he only had the money to pay for 4 basic labs.  On his blood count, he had anemia as expected.  And we saw it- MCV of 116.  Of course he would be folate/B12 deficient as well!  We quickly stopped Everth, the resident with the cute smirk, and reminded him the patient should be supplemented with these vitamins as well.  Sometimes it feels like we don't do much for the patient care here, so it felt good to put in that two cents.