Pellagra

Pellagra is a disease caused by a deficiency in the body of nicotinic acid and other b vitamins (thiamine, Riboflavin, pyridoxine, folic acid), and amino acids tryptophan and characterized by lesions of the skin, digestive tract, and nervous system can develop without enough food, and also be a consequence of a number of diseases (for example, organs of digestion). Predisposing factors: the defeat of the digestive tract, causing malabsorption of nutrients (ahilia, chronic enteritis and other); infection (acute dysentery, tuberculosis and other); alcoholism; excessive exposure to environmental factors (sun, UV rays); increased need of the body of nicotine acid (pregnancy, lactation, heavy physical work without enough food).
The pathogenesis of pellagra is not entirely clear. Morphologically dystrophic and degenerative changes in the skin, the Central and peripheral nervous system, digestive apparatus, endocrine glands, heart, skeletal muscle.
Patients complain of weakness, loss of appetite, parestesia (feeling numbness, tingling, begonia pins and needles), a burning sensation in the mouth, salivation, persistent diarrhea, abdominal pain.
pellagra

Fig. 1, 3 and 4. Skin lesion when pellagra. Fig. 2. Changes in the mucous membrane of the tongue when pellagra.


Objectively previously only detect changes in the skin and symptoms in the gastrointestinal tract and, later, neuropsychiatric disorders and depletion. Skin changes initially expressed by erythema, and in the current acute cases formation of blisters filled with muddy liquid, mostly in open areas of the body (face, neck, arms, legs); - excessive pigmentation (in the form of points collar), atrophy and sclerosis of the affected areas, as well as scaling and separate areas of keratinization (Fig. 1, 3 and 4). For the defeat of the gastrointestinal tract characteristic bright red tongue with atrophic, brilliant (as if polished), wounded mucous membrane (Fig. 2), ulcerative stomatitis, bloating, achlorhydria in gastric juice. In addition, there anemia with macrocytosis, moderate leukopenia. When pellagra can develop polyneuritis. Mental disorders are manifested apathy, fatigue, depression, impaired memory, sometimes psychosis, accompanied by hallucinations.
For pellagra is characterized by repeated exacerbations in the spring (insolation).
The differential diagnosis should be borne in mind edisonova disease, pernicious anemia, porphyrin disease.
Prognosis with proper treatment favorable.
Treatment in a hospital. Prescribed diet with sufficient amount of proteins, vitamins. It is important to include in the diet of meat, fresh fish, bread, buckwheat, peas, peanuts, liver, yeast. Prescribe nicotine amide or nicotinic acid inside of 0.1 g 3-4 times a day after meals, diseases of gastrointestinal tract, intramuscularly or intravenously for 5-10 ml of 1% solution of nicotine acid in 4-6 weeks. Simultaneously administered parenteral other b vitamins: thiamine (20-50 mg), Riboflavin (10-20 mg), pyridoxine (50 mg). Vitamin B12 (30 to 100 micrograms a day) is used in macrocytosis and glossitis. In severe depletion produce fractional blood transfusion (70-100 ml every 3-5 days under the supervision of a doctor). Only 5-6 transfusions during the period of illness.
To prevent pellagra need a variety of good nutrition with sufficient content in food antiparasitical factor (vitamin PP).
The clinical picture of pellagra in children differs little from pellagra in adults. The earliest manifestation of pellagra in children are persistent diarrhea, beyond the usual diet and medical means. Skin changes in children may be accompanied by itching. There are also disorders of the nervous system (psychoses almost never occur).
Treatment: in addition to the mental and physical rest and nutrition, appoint nicotinic acid inside children under 3-4 years 10-15 mg 2-3 times a day, in the preschool years, 20 to 30 mg, in a school in the 50-100 mg, as well as other vitamins b and C, a blood transfusion, blood and symptomatic funds.


Pellagra (from Italy. pelle agra - rough skin) - a disease clinically manifested by skin, digestive tract, and nervous system (the classical triad: dermatitis, diarrhea, dementia).
Etiology. The emergence of pellagra is associated with prolonged deficiency in the body of vitamins VIV first nicotinic acid (PP-vitamin deficiency), and amino acids - tryptophan. Predisposing factors: 1) the defeat of the digestive tract, causing malabsorption of nutrients (ahilia, chronic enteritis, condition after PoE stomach and small intestine, gastrointestinal fistula); 2) acute and chronic infections (acute dysentery, tuberculosis and other); 3) alcoholism; 4) the effect of environmental factors (insolation, ultraviolet rays); 5) the factors that increase the body's need of nicotine acid (pregnancy, lactation, heavy physical work without enough food).
The pathogenesis of pellagra is not clear. When lack of food nicotinic acid comes the violation of cellular respiration, which will entail the change of the functions of all organs and perversion of the main processes of metabolism, first of all carbohydrate. In addition, the mechanism of development of pellagra plays the role of a lack of other b vitamins, and proteins, in particular amino acids tryptophan.
With long-term disorders basic processes of metabolism in the pellagra come degenerative and atrophic changes in all tissues and organs, primarily in the skin, nervous system and gastrointestinal tract, and neurotrophic disorders.
There are primary form of pellagra-related malnutrition, and secondary resulting from other diseases, mainly digestive system.
Pathological anatomy. And degenerative dystrophic changes are detected in the skin (elastic fibers, sweat glands, nerves), cells and conducting systems of Central and peripheral nervous system, digestive system, endocrine glands, heart, skeletal muscle.
Clinical course and symptoms. Complaints of patients associated with the major defeats in pellagra: loss of appetite, dryness and burning in the mouth, a perversion of taste sensations, vomiting, diarrhea alternating with constipation, General progressive weakness, indifference to the surrounding, apathy, depression, forgetfulness, the sharp weakening of memory, headache, dizziness.
Typical is the passive position of the patient in bed. In rare cases there excited state.
The digestive system. Tongue edema, bright red, with painful Atami and superficial ulceration, those changes are observed in the lining of the cheeks and esophagus. Noted pain in podlojecna area.
In the study of gastric juice found achlorhydria. Motor function of the stomach is reduced. If rectoromanoscopy visible hyperemic swollen mucous membrane of the intestine is covered surface bleeding lesions. Sometimes ulcers.
The blood system. Anemia with high color record, macrocytosis, moderate leukopenia.
The nervous system. When pellagra can occur polyneuritis. They develop gradually, characterised by different paresthesia without the expressed pain of nerve trunks polyneuritises disorders of sensitivity. In addition polyneuritises phenomena can sometimes occur spinal and cerebral symptoms. More likely to suffer posterolateral columns of the spinal cord. In severe pellagra appear more severe changes of nervous system. Cerebral lesions can simulate clinical picture of brain tumors, acute cerebellar ataxia.
The endocrine system. Polyglandular insufficiency in P. appears low blood pressure, weakness, a weakness of the muscles, decreased metabolism, polyuria, depletion of bone calcium.
Protein and vitamin metabolism. There are hypoproteinemia, reduction of the content of albumin and increased the number of globulins. In the study of vitamin balance, show traces of nicotine acid and N1-methyl nicotine amid urine, lack of other b vitamins and reduction of ascorbic acid in the blood.
The clinical course there are acute and prolonged forms of P.
The acute form of pellagra develops on the background of malnutrition exogenous or endogenous origin. It should be emphasized that gastrointestinal disorders long precede the appearance of skin lesions. Chair quickens up to 10-15 times a day, it becomes liquid, no pain. Sometimes there spontaneous remission up to 2-3 weeks. Is characterized by a rapid development of neurological symptoms, with the heavier destruction of internal organs, the brighter expressed and neurological symptoms. In addition, in the acute form is observed intermittent psychosis with delirious and lentissimi components.
A protracted form of pellagra is characterized by effaced, abnormality and variability, the slow development of the main symptoms of the disease. For persistent form of pellagra greatest violations of the digestive tract is found in the small and blind guts that entails a violation of the processes of digestion and absorption of nutrients. Specific morphological changes of the mucous membrane of the intestines is not detected. For persistent form P. more common disorders of the peripheral nervous system (polyneuritis) and rarely spinal and cerebrospinal. The lack of interest in the environment, lowering memory, shared mental retardation, crying for no apparent reason characterize change of mentality in this form of pellagra. Changes in the blood and protein have different ways and atypical. The level of nicotine acid and N1-methyl nicotine amid, and other b vitamins, defined In the urine, low.
Changes in the skin when pellagra. When pellagra outlines the General dryness, hyperkeratosis, gray skin color. These phenomena are expressed especially on the sides of the torso, extensor surfaces of the upper and lower extremities.
On the face, neck, back surfaces of hands and footsteps are under the influence of sunlight arise erythematous patches cherry-red color, resembling a sunburn and have sharp boundaries. They gradually lose acute inflammatory color, pigmentosa. When acute P. observed exudative phenomena with the emergence of bubbles of various sizes, filled with hemorrhagic content, which then slowly opened and subcourse.
For pellagra most characteristic rash on the face and neck. On the eyelids may appear erythematous lesions in the form of a Crescent of Achkasov. Sometimes around the eyes and nose leather has a reddish-brown color, flakes (Tallahassee points). Peligrosa erythema on the neck is a strip surrounding the neck and going down to the breastbone (the collar of Casale).
Lesions are often located also on the back surfaces of hands, in the area of the beam-carpal joint, and at the base of the terminal phalanges. Sometimes peligrosa erythema occurs in the ankle joint, surrounding it in the form of a bracelet.
In addition to the typical lesions Pellegrini erythema, P. often observed follicular papules on the shins and thighs with hemorrhage around. Many patients are affected mucous membranes of the oral cavity, nose, conjunctiva, genitals.
In light nerezko expressed the form P. - Pellegrini - there are only skin changes.
The diagnosis of an acute form in the presence of the classic triad (dermatitis, diarrhea, dementia) in most cases not difficult. Sometimes mistakenly diagnosed faces, solar dermatitis, exudative erythema.
A protracted form of pellagra difficult to diagnose. Light it forms are often unrecognized or diagnosis of diseases of the bowel (if diarrhea). Protracted forms should be differentiated from edisonova disease (see) and anemia Addison - Biermer (see Anemia).
In correct diagnosis along with clinical data has value determination in urine nicotine acid and other b vitamins Century
The forecast is favorable for life in modern methods of treatment. Ability to work in protracted forms can be restored with long-term (months) systematic treatment against the background of adequate nutrition.
Treatment. The patient should be provided with stationary treatment (physical and mental rest, thermal regime). Appoint nicotinic acid amide or nicotinic acid inside of 0.1 g 3-4 times a day after meals, intramuscularly or intravenously for 5-10 ml of 1% solution for 4-6 weeks. As remission painful process, the amount of nicotinic acid is reduced to 50 mg per day. This number is assigned in long-term treatment of prolonged illness.
Parenteral introduction of nicotinic acid effectively orally, but more often causes painful sense of warmth, itching, redness of the face, neck, and extremities. Much easier patients tolerate amide, nicotinic acid. It is advisable to appoint a thiamine (20-50 mg), Riboflavin (10-20 mg), pyridoxine (50 mg) parenteral. Vitamin B12 (30 to 100 micrograms a day) shown in the event hyperchromia, macrocytosis and glossitis. In severe depletion should be appointed fractional blood transfusion (75-100 ml every 3-5 days). Only 5-6 transfusions during the period of illness.
The next important link in the treatment of pellagra is proper nutrition. The number of calories should be increased gradually. In the first weeks of treatment it should be not above 3000. Food should be fractional (4-5 times a day).
In the diet should include 90 grams of protein per day and gradually increase up to 120-150 g, vitamin a (5000 ME). ascorbic acid, vitamins b (yeast, bran).
When Pellegrini diarrhea maintain good nutrition, only apply the principle of sparing of mechanical.
Of drugs long-designate of hydrochloric acid gastric juice, drugs pancreas, at diarrheas - sulfa drugs (sulgin 2 g for 5 days) or antibiotics (oletetrin 250 000 IU 4 times a day for 5 days). Taking sulfanilamidami and antibiotics should be combined with vitamins and nystatin.
Prevention. To prevent the development of pellagra need a variety of good nutrition with sufficient content in food antiparasitical factor (RR). Daily need of a healthy person in nicotine acid is 15-25 mg
A relatively large number of nicotinic acid contain wheat (500 g of wheat bread are daily allowance (RDA) nicotinic acid), yeast. Sources of nicotinic acid are the liver, beef, pork, lamb, salmon, crabs.
Milk poor nicotinic acid, but rich in tryptophan, which nicotinic acid is synthesized in the body.
In the prevention of secondary P. great importance of parenteral introduction, respectively, high doses of nicotinic acid and other b vitamins in cases involving a violation of intake of nutrients, as well as acute and chronic infections.