Review Question - QID 108968

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Vitamin B3 (Niacin) Deficiency Presentation QID: 108968 (M2.NT.17.4754)

QID 108968 (Type "108968" in App Search)

A 64-year-old male is brought in by his granddaughter for confusion. She reports that since her grandmother died six months ago, the patient has become increasingly more irritable. Then yesterday, a neighbor called to say that she had found him aimlessly walking up and down the street. When the granddaughter went to check on him, she reported that there were multiple empty cans of beer and minimal food in the house. The patient has a past medical history significant for hypertension for which he takes chlorothiazide. His surgical history is significant for cataract surgery one year ago. When the patient is asked about his alcohol use, he angrily responds that it is “none of your business.” When asked about diet and weight loss, he admits that he eats very little due to his ongoing diarrhea. On physical exam, you note muscle wasting, balding, and a diffuse rash on his arms and legs, as shown in Figure A. What is the treatment of choice?

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Thiamine

15%

10/66

Riboflavin

1/66

Niacin

80%

53/66

Pantothenic acid

0/66

Zinc

2/66

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The patient is presenting with dementia, diarrhea, and dermatitis of sun-exposed areas, suggesting the diagnosis of pellagra caused by malnutrition. The treatment of choice is niacin.

Pellagra is caused by deficiency of niacin (vitamin B3). In addition to dietary deficiencies, other causes of pellagra include Hartnup disease, malignant carcinoid syndrome, and isoniazid. Symptoms of pellagra include diarrhea, dementia, dermatitis, and glossitis. Changes in mental status and personality, such as irritability and poor concentration, can occur prior to symptoms of dementia and/or hallucinations. Dermatitis can present as a Casal necklace (Illustration A), which is a C3/C4 circumferential broad collar rash, or redness/hyperpigmentation of sun-exposed areas (Figure A). Niacin supplements would be the treatment of choice.

Figure A shows dermatitis, or dry skin and inflammation, on the legs. Illustration A shows a Casal necklace, or a circumferential, 'broad collar' rash within the C3/C4 dermatome regions, characteristic of pellagra. Illustration B shows acrodermatitis enteropathica, an inflammatory rash around the mouth or anus, associated with zinc deficiency.

Incorrect Answers:
Answer 1: Thiamine (vitamin B1) deficiency causing Wernicke-Korsakoff syndrome may be common in alcoholics and malnutrition and can be associated with confusion and confabulation but would not explain the patient’s rash. Additional symptoms for Wernicke-Korsakoff include ophthalmoplegia and ataxia.

Answer 2: Riboflavin (vitamin B2) deficiency is associated with chelitis, which is an inflammation of lips and peri-oral fissures, corneal vascularization, and seborrheic dermatitis.

Answer 4: Pantothenic acid (vitamin B5) deficiency is associated with dermatitis, enteritis, and alopecia but would not explain the patient's dementia. B5 deficiency can also be associated with adrenal insufficiency and refractory hypertension.

Answer 5: Zinc deficiency is associated with acrodermatitis enteropathica (Illustration B), which is an inflammatory rash around the mouth and/or anus, and alopecia but would not explain the patient's confusion or diarrhea. Zinc deficiency is also associated with delayed wound healing, hypogonadism, and anosmia.

Bullet Summary:
Pellagra is caused by deficiency in niacin (vitamin B3). Symptoms of pellagra include diarrhea, dementia, dermatitis, and glossitis; treatment of choice is niacin supplements.

ILLUSTRATIONS:

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