Pellagra and anorexia nervosa: a case report
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CASE REPORT
Pellagra and anorexia nervosa: a case report Sandra Portale1 · Michele Sculati2 · Fatima Cody Stanford3,4 · Hellas Cena1,5 Received: 12 March 2019 / Accepted: 9 September 2019 © Springer Nature Switzerland AG 2019
Abstract Background While pellagra appears to be a rare entity currently, it may still develop. It is important to recognize how the disease manifests to ensure adequate and timely treatment. Case presentation We present a case of pellagra secondary to anorexia nervosa in a 28-year-old woman. We observed the classical signs: erythema in the neck region, diarrhea, and neurologic symptoms. Diagnosis was made on a clinical basis, and the patient had a rapid recovery after undergoing therapy with nicotinamide and tryptophan. Conclusions In our case, the patient did not exhibit any sign of being severely underweight with marked malnutrition such as the typical manifestation expected in pellagra. This case demonstrated that clinicians should have a high level of suspicion in making a diagnosis of pellagra, especially in patients with a history of eating disorders. Level of evidence IV (case study). Keywords Pellagra · Niacin deficiency · Anorexia nervosa · Case report
Introduction Pellagra is a condition characterized by the lack of niacin (vitamin B3) or tryptophan (precursor of niacin, 60 mg is equivalent to 1 mg of niacin) [1]. Niacin has two forms (niacin and niacinamide) and is fundamental in nicotinamide adenine dinucleotide (NAD) biosynthesis which has Sandra Portale and Michele Sculati equally contributed to this article. * Sandra Portale [email protected] 1
Laboratory of Dietetics and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Via Bassi 21, 27100 Pavia, PV, Italy
2
Department of Public Health, Experimental and Forensic Medicine, Master Course in Dietetics and Clinical Nutrition, University of Pavia, Via Bassi 21, 27100 Pavia, PV, Italy
3
Department of Medicine‑Neuroendocrine Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
4
Department of Pediatrics‑Endocrinology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
5
Clinical Nutrition and Dietetics Service, Unit of Internal Medicine and Endocrinology, ICS Maugeri IRCCS, Via S.Maugeri 10, 27100 Pavia, PV, Italy
a central role in cellular homeostasis and energy regeneration [2]. In the past, pellagra was caused by a diet which consisted of corn or other plants [3]. Flour fortification with niacin and access to more diverse food sources have essentially led to its eradication in western countries [4]. However, there seems to be a reemergence of pellagra, which has been observed in patients with anorexia nervosa (AN) or HIV [5]. Three different etiopathogenetic mechanisms of pellagra can be described: (i) an alteration of the tryptophan intake, absorption and/or metabolism due to prolonged diarrhea, severe dietary restriction, chronic alcoholi
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