Pellagrous encephalopathy presenting as alcohol withdrawal delirium: A case series and literature review

Addiction Science & Clinical Practice

Mark A Oldham¹  Ana Ivkovic¹ 

[1] Boston University Medical Center, 850 Harrison Ave., Dowling 7S, Boston, MA, 02118, USA

关键词: Delirium tremens;    Vitamin B3 deficiency;    Niacin deficiency;    Pellagrous encephalopathy;    Pellagra;    Alcohol withdrawal delirium;   

Others  :  789366
DOI  :  10.1186/1940-0640-7-12

 received in 2011-10-09, accepted in 2012-06-25,  发布年份 2012

【 摘 要 】

Background

Alcohol withdrawal delirium (AWD) is associated with significant morbidity and mortality. Pellagra (niacin deficiency) can be a cause of delirium during alcohol withdrawal that may often be overlooked.

Objectives

We present a three-patient case series of pellagrous encephalopathy (delirium due to pellagra) presenting as AWD.

Methods

We provide a brief review of pellagra’s history, data on pellagra’s epidemiology, and discuss pellagra’s various manifestations, particularly as related to alcohol withdrawal. We conclude by providing a review of existing guidelines on the management of alcohol withdrawal, highlighting that they do not include pellagrous encephalopathy in the differential diagnosis for AWD.

Results

Though pellagra has been historically described as the triad of dementia, dermatitis, and diarrhea, it seldom presents with all three findings. The neurocognitive disturbance associated with pellagra is better characterized by delirium rather than dementia, and pellagra may present as an isolated delirium without any other aspects of the triad.

Discussion

Although endemic pellagra is virtually eradicated in Western countries, it continues to present as pellagrous encephalopathy in patients with risk factors for malnutrition such as chronic alcohol intake, homelessness, or AIDS. It may often be mistaken for AWD. Whenever pellagra is suspected, treatment with oral nicotinamide (100 mg three times daily for 3–4 weeks) prior to laboratory confirmation is recommended as an inexpensive, safe, and potentially life-saving intervention.

【 授权许可】

   
2012 Oldham and Ivkovic; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Hack JB, Hoffman RS, Nelson LS: Resistant alcohol withdrawal: does an unexpectedly large sedative requirement identify these patients early? J Med Toxic 2006, 2(2):55-60.
• [2]Khan A, Levy P, DeHorn S, Miller W, Compton S: Predictors of mortality in patients with delirium tremens. Acad Emerg Med 2008, 15(8):788-790.
• [3]Kahn DR, Barnhorst AV, Bourgeois JA: A case of alcohol withdrawal requiring 1,600 mg of lorazepam in 24 hours. CNS Spectr 2009, 14(7):385-389.
• [4]McCowan C, Marik P: Refractory delirium tremens treated with propofol: a case series. Crit Care Med 2000, 28(6):1781-1784.
• [5]Dastur DK, Santhadevi N, Quadros EV, Avari FC, Wadia NH, Desai MN, Bharucha EP: The B-vitamins in malnutrition with alcoholism. A model of intervitamin relationships. Br J Nutr 1976, 36(2):143-159.
• [6]: Lishman's Organic Psychiatry: A Textbook of Neuropsychiatry. 4th edition. Edited by David AS, Fleminger S, Kopelman MD, Lovestone S, Mellers JDC. Wiley-Blackwell, Oxford; 2009.
• [7]Russell RM, Suter PM: Vitamin and trace mineral deficiency and excess. In Harrison’s Principles of Internal Medicine. 18th edition. Edited by Longo DL, Fauci AS, Kasper DL, Hauser S, Jameson JL, Loscalzo J. McGraw-Hill, New York; 2012.
• [8]Cook CCH, Hallwood PM, Thomson AD: B vitamin deficiency and neuropsychiatric syndromes in alcohol misuse. Alcohol Alcohol 1998, 33(4):317-336.
• [9]Ishii N, Nishihara Y: Pellagra among chronic alcoholics: clinical and pathological study of 20 necropsy cases. J Neurol Neurosurg Psychiatry 1981, 44:209-215.
• [10]Serdaru M, Hausser-Hauw C, Laplane D, Buge A, Castaigne P, Goulon M, Lhermitte F, Hauw JJ: The clinical spectrum of alcoholic pellagra encephalopathy. A retrospective analysis of 22 cases studied pathologically. Brain 1988, 111(pt 4):829-842.
• [11]Wilson WH: The diet factor in pellagra. J Hyg (Lond) 1921, 21(1):1-59.
• [12]Blue R: Pellagra in California. Cal State J Med 1910, 8(3):101-102.
• [13]Klauder JV, Winkelman NW: Pellagra among chronic alcoholic addicts. JAMA 1928, 90:364-371.
• [14]Goldberger JG, Wheeler GA, Lillie RD, Rogers LM: A further study of butter, fresh beef and yeast as pellagra preventives, with consideration of the relation of factor P-P of pellagra (and black tongue of dogs) to vitamin B. Public Health Rep 1926, 41:297-318.
• [15]Koehn CJ, Elvehjem CA: Further studies on the concentration of the antipellagra factor. J Bio Chem 1937, 118(3):693-699.
• [16]Park YK, Sempos CT, Barton CN, Vanderveen JE, Yetley EA: Effectiveness of food fortification in the United States: the case of pellagra. Am J Public Health 2000, 90:727-738.
• [17]Wildman RE, Medeiros DM: Advanced Human Nutrition. CRC Press, Boca Raton, FL; 2000:521.
• [18]Sardesai VM: Introduction to Clinical Nutrition. Marcel Dekker, New York; 1998:179-186.
• [19]US Institute of Medicine: Dietary Reference Intakes for Thiamin, Riboflavin, Niacin, Vitamin B6, Folate, Vitamin B12, Pantothenic Acid, Biotin, and Choline. National Academy Press, Washington, DC; 1998:123-149.
• [20]Dalgliesh CE: Interrelationships of tryptophan, nicotinic acid and other B vitamins. Betr Med Bull 1956, 12:49-51.
• [21]Burton BT: Human Nutrition. 3rd edition. H. J. Heinz/McGraw Hill, New York; 1976:490-513.
• [22]Hauw JJ, De Baecque C, Hausser-Hauw C, Serdaru M: Chromatolysis in alcoholic encephalopathies. Pellagra-like changes in 22 cases. Brain 1988, 111(pt 4):843-857.
• [23]Paulionis L, Kane SL, Meckling KA: Vitamin status and cognitive function in a long-term care population. BMC Geriatr 2005, 5:16. BioMed Central Full Text
• [24]Jacobson EL: Niacin deficiency and cancer in women. J Am Coll Nutr 1993, 12:412-416.
• [25]World Health Organization: The management of nutrition in major emergencies. , Geneva; 2000:31-32.
• [26]Dawson B, Favaloro EJ, Taylor J, Aggarwal A: Unrecognized pellagra masquerading as odynophagia. Intern Med J 2006, 36(7):472-474.
• [27]Gillman J, Gillman T: Perspectives in Human Malnutrition: A Contribution to the Biology of Disease From a Clinical and Pathological Study of Chronic Malnutrition and Pellagra in the African. Grune & Stratton, New York; 1951.
• [28]Kertesz SG: Pellagra in 2 homeless men. Mayo Clin Proc 2001, 76:315-318.
• [29]Spivak JL, Jackson DL: Pellagra: an analysis of 18 patients and a review of the literature. Johns Hopkins Med J 1997, 140:295-309.
• [30]Varella Morandi Junqueira-Franco M, Ernesto Troncon L, Garcia Chiarello P, do Rosário Del Lama Unamuno M, Afonso Jordao A, Vannucchi H: Intestinal permeability and oxidative stress in patients with alcoholic pellagra. Clin Nutr 2006, 25:977-983.
• [31]Committee on Statistics of the American Medico-Psychological Association: Statistical Manual for the Use of Institutions for the Insane. , New York; 1918:21.
• [32]Charness ME: Brain lesions in alcoholics. Alcohol Clin Exp Res 1993, 17(1):2-11.
• [33]Brown TM: Pellagra: An old enemy of timeless importance. Psychosomatics 2010, 51:93-97.
• [34]Feinman L: Absorption and utilization of nutrients in alcoholism. Alcohol Health Res World 1989, 13(3):207-210.
• [35]World Health Organization: Pellagra and its prevention and control in major emergencies.   ,  : . http://whqlibdoc.who.int/hq/2000/who_nhd_00.10.pdf webcite on March 7, 2012
• [36]US Agency of International Development Fortification Basics: Stability.   , : . http://www.dsm.com/en_US/downloads/dnp/51610_fort_basics_stability.pdf webcite
• [37]Cambridge Biomedical Inc: Vitamin B3 Niacin.   , : . http://cambridgebiomedical.com/media/PDFLibrary/TechBriefs/Vitamin%20B3%20Niacin%2010-03-12.pdf webcite
• [38]Food and Drug Administration: Niacin.   , : . http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682518.html webcite
• [39]Rajakumar K: Pellagra in the United States: a historical perspective. South Med J 2000, 93:272-277.
• [40]Das R, Parajuli S, Gupta S: A rash imposition from a lifestyle omission: a case report of pellagra. Ulster Med J 2006, 75(1):92-93.
• [41]Prakash R, Gandotra S, Singh LK, Das B, Lakra A: Rapid resolution of delusional parasitosis in pellagra with niacin augmentation therapy. Gen Hosp Psychiatry 2008, 30:581-584.
• [42]Delgado-Sanchez L, Godkar D, Niranjan S: Pellagra: rekindling of an old flame. Am J Ther 2008, 15(2):173-175.
• [43]Okan G, Yaylaci S, Alzafer S: Pellagra: will we see it more frequently? J Eur Acad Dermatol Venereol 2009, 23(3):365-366.
• [44]Waterlot Y, Sabot JP, Marchal M, Vanherweghem JL: Pellagra: Unusual cause of paranoid delirium in dialysis. Nephr Dial Transplant 1986, 1:204-205.
• [45]Zimmerman HM, Cohen LH, Gildea EF: Pellagra in association with chronic alcoholism. Arch Neurol Psychiatry 1934, 31(2):290-309.
• [46]Jolliffe N, Bowman KM, Rosenblum LA, Fein HD: Nicotinic acid deficiency encephalopathy. JAMA 1940, 114(4):307-312.
• [47]Victor M: Persistent altered mentation due to ethanol. Neurol Clin 1993, 11(3):639-661.
• [48]Pandharipande P, Shintani A, Peterson J, Pun BT, Wilkinson GR, Dittus RS, Bernard GR, Ely EW: Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients. Anesthesiology 2006, 104(1):21-26.
• [49]Mayo-Smith MF, Beecher LH, Fischer TL, Gorelick DA, Guillaume JL, Hill A, Jara G, Kasser C, Melbourne J: Management of alcohol withdrawal delirium. An evidence-based practice guideline. Arch Intern Med 2004, 164:1405-1412.
• [50]Myrick H, Anton RF: Treatment of alcohol withdrawal. Alcohol Health Res World 1998, 22(1):38-43.
• [51]American Psychiatric Association: Practice Guidelines for the Treatment of Patients with Substance Use Disorders. 2nd Edition. IV. Treatment of alcohol-related disorders.   , : . http://www.psychiatryonline.com/content.aspx?aID=142085 webcite
• [52]Royal College of Physicians: Alcohol Use Disorders: Diagnosis and Clinical Management of Alcohol-Related Physical Complications.   , : . http://www.nice.org.uk/nicemedia/live/12995/48989/48989.pdf webcite
• [53]Ashworth M, Gerada C: BC of mental health. Addiction and dependence—II: Alcohol. BMJ 1997, 315(7104):358-360.
• [54]Cook CC, Thomson AD: B-complex vitamins in the prophylaxis and treatment of Wernicke − Korsakoff syndrome. Br J Hosp Med 1997, 57(9):461-465.
• [55]Cook CC, Thomson AD: Treating alcohol dependence. Supplementation with parenteral B vitamins should be routinely considered. BMJ 1997, 315(7120):1465.
• [56]Walker L, Brown P, Beeching NJ, Beadsworth MB: Managing alcohol withdrawal syndromes: the place of guidelines. Br J Hosp Med (Lond) 2009, 70(8):444-449.
• [57]Ward D, Murch N, Agarwal G, et al.: A multi-centre survey of inpatient pharmacological management strategies for alcohol withdrawal. QJM 2009, 102(11):773-780.