Pellagra And Malnutrition

Introduction

Pellagra is a condition caused by a deficiency of vitamin B3, also known as niacin, in the diet, or the inability to absorb it through the diet. It affects the gut, the skin and the central nervous system. Malnutrition is the leading cause of pellagra, particularly in populations with poor nutritional diets that do not contain vitamin B3. The disease is characterised by the “4Ds”: dermatitis, diarrhoea, dementia and death (if left untreated).¹ 

Pellagra is more prevalent in developing countries where poverty and the lack of awareness about the need for certain vitamins and their importance contribute to rising cases. In developed countries, pellagra has been largely eradicated due to foods being fortified with vitamin B3 as well as a better understanding of nutritional value. In these countries, cases are due to secondary causes such as people not being able to absorb vitamin B3, alcohol abuse or eating disorders. Pellagra is a treatable condition if diagnosed early.² 

History of pellagra

Pellagra was first mentioned in 1735 by Gasper Casal y Julian in Spain. High incidence in Italy and Spain caught the attention of doctors so, in 1778, Italian doctor Gaetano Strambio set up a special hospital for pellagra patients in Legnago, Italy. In the US it was first identified in 1906 by Dr George H. Searcy, who saw pellagra affecting 88 mentally ill patients at the Mount Vernon Insane Hospital in Alabama. 

Not having an idea of the cause of pellagra and being unable to stop it, it spread like wildfire in southern America. A public health official called Dr. Joseph Goldberger was the first to correctly identify the main cause of pellagra. Experimenting in Southern orphanages and prisons, Goldberger found that the disease was not infectious as previously believed, but resulted from an inadequate diet. 

In 1937, Conrad Elvehjem, a biochemistry professor, demonstrated that vitamin B3 can cure pellagra in dogs. Subsequently, Dr. Tom Spies and his colleagues confirmed that vitamin B3 also cured pellagra in humans.³

Vitamin B3

Vitamin B3 is a member of the B-complex family, which consists of eight vitamins. These eight vitamins play a crucial role in converting the food we eat into fuel, which the body uses to produce energy for normal function. B vitamins are important to keep the liver, skin, hair, and eyes in good health and to help the nervous system function properly. Other benefits include improving blood flow throughout the body and protecting against inflammation.

As B vitamins are water-soluble, they cannot be stored by the body, so you need to get them through the food you eat. A healthy and balanced diet should provide sufficient amounts of vitamin B for your body. Another way to increase vitamin B3 intake is by consuming foods rich in tryptophan. Tryptophan is present in many animal and plant-based foods including chicken, red meat, milk, eggs, oats and chocolate. It is needed for good general development and for serotonin production. Tryptophan can also be converted to vitamin B3, although you would need a large amount of it so it is not as efficient as consuming vitamin B3 directly. 

Examples of foods containing high levels of vitamin B3 are:

• Beans
• Brewer's yeast
• Beef liver
• Beef kidney
• Salmon
• Swordfish
• Tuna
• Sunflower seeds
• Peanuts

Types of pellagra

Primary pellagra occurs when you have very low levels of vitamin B3 or tryptophan in your body. The body can convert tryptophan in foods to vitamin B3. In parts of the world where maize is a staple food such as Africa, the risk of developing pellagra is high as maize naturally has lower levels of vitamin B3. In addition, any vitamin B3 in maize cannot be absorbed unless it has been through the nixtamalization process, which involves soaking and cooking the corn in an alkaline solution.⁴

Secondary pellagra is caused by the body’s inability to absorb vitamin B3 from food properly. Certain medications and illnesses have been implicated in this such as:

• Hartnup disease prevents the body from absorbing tryptophan
• Tuberculosis treatments such as isoniazid have a similar structure to vitamin B3 so can take its place when being absorbed
• In Carcinoid syndrome, tumours use tryptophan to make a lot of serotonin, instead of converting to vitamin B3, reducing its levels 
• Human Immunodeficiency Virus 
• Anorexia 
• Chronic alcoholism and/or drug abuse
• Liver cirrhosis
• Patients receiving long-term dialysis

Symptoms of pellagra

Symptoms of vitamin B3 deficiency can be divided into the following categories:⁵

Skin symptoms

• Skin can look like it has a rash or a sunburn on exposed skin 
• There is skin discolouration and peeling off as it progresses with a feeling of burning 
• The skin blisters, become tough and scaly
• Typically both sides of the body are affected ie both hands or feet
• Malar rash pattern on the face, hands, feet, and neck
• Skin becomes sensitive to the sun
• Affected areas are itchy and painful

Gastrointestinal symptoms

• Having no appetite, feeling sick with irritation in the upper GI tract and abdominal pain
• The stomach lining can become inflamed and stop producing gastric acid for digestion
• Inflammation of the tongue and pain in the mouth can lead to difficulty in swallowing 
• Diarrhoea is typically watery but is occasionally bloody

Neurological symptoms

• Loss of energy and enthusiasm can lead to depression and feeling anxious
• Difficulties in being able to concentrate and becoming prone to irritability
• As the disease progresses, symptoms such as disorientation, confusion and delirium become common
• Becoming increasingly dazed and unaware of their surroundings, putting them at risk of becoming comatose

If left untreated, pellagra will eventually cause the death of the patient. But treatments are available and patients can recover from the disease if medical help is sought as quickly as possible.

Prevention of pellagra

If you are at high risk of developing pellagra, there are preventative measures that can be taken to reduce the chances, which are:

• Taking the recommended daily allowance of 15-20 mg of vitamin B3 can prevent pellagra
• Use vitamin B3 supplements if you are taking medications that interfere with its absorption
• Applying creams and ointments to treat skin issues
• Seeking medical help for alcoholism, anorexia and issues with vitamin B3 absorption

Treatment of pellagra

Firstly, a diet with plenty of vitamins, minerals, and high-calorie foods is recommended to boost the general wellness of the patient. This helps with symptoms and educates the patient on which foods are best and how to prepare them. 

Doses of between 250 and 500 mg of nicotinamide (another form of vitamin B3) daily by mouth are recommended to treat pellagra. Nicotinamide is preferred as it is tolerated better by the body and doesn't cause skin flushing or itching. Overall improvement of the nutritional status of the patient is essential to address malnutrition symptoms, which may involve taking additional supplements. Patients are advised to protect their skin from the sun to avoid further damage by the sun rays and also limit the amount of alcohol they drink. The majority of the symptoms may improve in a couple of weeks, but severe disease will take longer to recover from, with some changes a lifelong necessity.⁵ 

Safety and side effects

If you consume vitamin B3 as part of a balanced diet, it is generally safe. However, very high doses of vitamin B3 (over 2000mg) can cause the following side effects:

• Dizziness
• Rapid heartbeat
• Itching
• Nausea and vomiting
• Abdominal pain
• Diarrhoea
• Gout
• Liver damage
• Diabetes

Summary

Pellagra, caused by a deficiency in vitamin B3, is an entirely preventable condition through a well-balanced diet. It is important that in countries where poverty is high, there are mechanisms in place to make sure that people are able to find sufficient food. Food security is essential to help with conditions related to diet and access to food. Creating awareness is also important, so people know what causes pellagra and how to prevent it. As is common in Western countries, fortifying food with vitamin B3 can almost eradicate primary pellagra and that should be the goal for public health officials all over the world. Diagnosing pellagra early can help with swift recovery so better strategies are needed to improve medical access for remote places with little or no health coverage.