Pellagra I a 45-Year-Old Man

FIGURE A

For 4 months, a 45-year-old man with a history of alcohol abuse had made multiple visits to the emergency department (ED) and a dermatology clinic for evaluation of a diffuse, scaly, and intensely pruritic rash. The rash, which was photosensitive, had started on his upper extremities and spread proximally to the trunk and lower extremities.

FIGURE B

Because of the pruritic nature of his rash, he was given empiric treatment for scabies with antihistamines and topical corticosteroids. Over the next few months, edema developed in the lower extremities and the rash progressed. In follow-up clinic visits, these new changes were attributed to medication adverse effects, yet he continued to be treated under the assumption that this was scabies.

Approximately 3 months later, the patient presented to the ED in acute renal failure (creatinine level, 9.16 mg/dL). He was cachectic and dehydrated and had a diffuse macular, erythematous, scaling rash on the bilateral upper and lower extremities (A and B), abdomen (C), and lower back (D).Closer examination of the patient’s history revealed a 30-lb weight loss from 6 months of emesis, abdominal pain, diarrhea, dysgeusia, and intermittent dysphagia. Cognitive symptoms included mental confusion, short-term memory loss, and visual hallucinations of parasites crawling out of his skin. The patient admitted to drinking 18 to 24 alcoholic beverages daily for several years, although his dysgeusia had led to abstinence from drinking for 4 months before presentation. A diagnosis of pellagra was made on the basis of the characteristics of his rash, presence of diarrhea, cognitive impairment, history of alcoholism, and poor nutrition. No definitive laboratory test exists for the diagnosis of pellagra.

Upper GI endoscopy revealed erosive esophagitis and duodenitis consistent with mucosal inflammation. Test results showed no evidence of the presence of heavy metal or Clostridium difficile infection.

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