Pellagra and Alcohol Dependence Syndrome: Findings From a Tertiary Care Addiction Treatment Centre in India

Alcohol and Alcoholism, 2019, 54(2) 148–151 doi: 10.1093/alcalc/agz004 Advance Access Publication Date: 5 February 2019 Article Article Pellagra and Alcohol Dependence Syndrome: Findings From a Tertiary Care Addiction Treatment Centre in India Venkata Lakshmi Narasimha1, Suhas Ganesh2, Sarath Reddy1, Lekhansh Shukla3, Diptadhi Mukherjee1, Arun Kandasamy1,*, Prabhat K. Chand1, Vivek Benegal1, and Pratima Murthy1 1 Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Bengaluru 560029, India, 2Schizophrenia Neuropharmacology Research Group at Yale (SNRGY), Department of Psychiatry, Yale University, New Haven, CT, USA, and 3Department of Psychiatry, AIIMS Bhopal, India *Corresponding author: Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neurosciences (NIMHANS), Hosur road, Bengaluru 560029, India. Tel.: +91-9008977699; E-mail: Received 24 September 2018; Revised 12 December 2018; Editorial Decision 8 January 2019; Accepted 9 January 2019 Abstract Aim: To define the prevalence and clinical presentation of pellagra, a multi-systemic disease caused by the deficiency of niacin, in patients admitted to a tertiary addiction treatment centre in southern India, with alcohol dependence syndrome (ADS)—(ICD10). Methods: Review of the health records of 2947 patients who received inpatient care for ADS between 2015 and 2017. Results: Out of 2947, 31 (1%) were diagnosed with pellagra. Nearly two-thirds (64.5%) of those with pellagra were from a low-income group. Of the clinical-triad of pellagra, all patients had dermatitis, more than half (58%) had delirium, a minority (19%) had diarrhoea. Nearly two-thirds (61%) had presented in a complicated-withdrawal state. Associated conditions included peripheral neuropathy (32%); Wernicke’s encephalopathy (26%); seizures (16%). Seventeen (54%) had BMI <18.5 kg/m2. Treatment was a high dose of parenteral vitamins including niacin (mean dose: 1500 mg/day) for an average of 7.5 days followed by oral multivitamin supplements. All had complete resolution of pellagrous symptoms by the end of the three weeks of inpatient care. Conclusions: Pellagra is an acute medical condition, frequently encountered in the context of alcohol dependence and poverty. It often presents with other disabling and life-threatening comorbidities like delirium tremens and Wernicke’s encephalopathy. The classical triad of pellagra is only seen in a minority of cases. Thus a high index of suspicion is required lest pellagra may remain undiagnosed. Prompt identification and treatment with a high dose of niacin in combination with other vitamins result in complete recovery. INTRODUCTION Pellagra is a disease caused by the deficiency of niacin and/or its precursor tryptophan and is compounded by other vitamin-B deficiencies. Painstaking documentation of symptoms in eighteenth-century European asylums, where patients were available for frequent assessment christened pellagra as ‘disease with four D’s’—sun-sensitive Dermatitis, Diarrhoea, Dementia, and ominously Death (Bryan and Mull, 2015). However, these classic symptoms rarely occur © The Author(s) 2019. Medical Council on Alcohol and Oxford University Press. All rights reserved. 148 149 Alcohol and Alcoholism, 2019, Vol. 54, No. 2 METHODS We carried out a review of the electronic health record database of patients admitted to a tertiary care addiction treatment centre in south India, during the years 2015–2017. The data were collected by two investigators who reviewed each case-record independently. Patients who received inpatient care, diagnosed with alcohol dependence syndrome (ADS) as per the 10th edition of the International Classification of Diseases (ICD10) (WHO, 1992) along with pellagra during the specified period, were included in the study. A clinical diagnosis of pellagra was reached if there was a classical skin lesion suggestive of pellagra with typical distribution and zone of demarcation, along with a preceding history suggestive of poor dietary intake and rapid improvement with niacin supplementation (Hegyi et al., 2004). All these cases have been seen by at least one of the authors and in most cases by two authors of this report, before being diagnosed with pellagra. Sociodemographic data, clinical measures of alcohol use pattern, clinical presentation and treatment details were collected from the case records. A body mass index (BMI) <18.5 kg/ 2947 patients admitted with alcohol dependence during the study period 38 patients diagnosed with pellagra 7 patients who were admitted twice, their 2nd admission was excluded 31 patients included in the study Fig. 1. Flow diagram of patient identification. m2 is defined as undernutrition and haemoglobin concentration less than 12.5 gm/dL is defined as anaemia. Figure 1 describes the process of patient identification from the clinical records. RESULTS Sociodemographic details A total of 2947 patients were admitted to the addiction treatment centre during the study period (2015–2017) for treatment of ADS (ICD10, F10.2). Among them, 31 (1% of total admissions) were diagnosed as having pellagra. Twenty-one (68%) were from an urban background, 20 (65%) were from a low-income group [defined as an annual income of <15,000 INR]. Only 4 (13%) had 10 or more years of formal education. Mean age at admission was 41.5 years (SD = 8.4 years). Clinical measures Mean duration of regular alcohol use in the pellagra group was 20.6 years (SD = 9.2 years). Average daily intake of alcohol was 20 units/day (SD = 8 units) where one unit is approximately equal to 13 g of pure ethanol. Height measurements of six subjects were missing in the records; for the remaining group (N = 25) mean BMI was 18.3 kg/m2 (SD = 2.1 kg). Seventeen patients (54%) had BMI <18.5 kg/m2, and 14 had haemoglobin <12.5 g/dL. Twenty patients (61%) had complicated withdrawal which included delirium tremens, withdrawal seizures or alcoholic hallucinosis. Mean duration of delirium was 6.2 days. Due to the inclusion criteria all patients had characteristic dermatitis (100%), 18 (58%) had delirium and 6 (19.5%) had diarrhoea. Only 3 (10%) cases had all three symptoms of the triad; 21 (68%) had at least 2 symptoms; while, 7 (22.5%) had only a single symptom, i.e. dermatitis. While 548 (18.5%) of the 2916 nonpellagra patients had delirium, the prevalence of delirium in patients with a diagnosis of pellagra was significantly higher (p1 = 0.185, n1 = 2916, p2 = 0.58, n2 = 31, P = 0.192, z = −5.6, P < 0.0001). Among the comorbidities, 8 (25.8%) of patients had Wernicke’s encephalopathy, and 10 (32.3%) had peripheral neuropathy. The prevalence of Wernicke’s encephalopathy in patients with pellagra was significantly higher compared to the prevalence of this condition in the total number of admissions (p1 = 0.033, n1 = 2916, p2 = 0.258, n2 = 31, P = 0.04, z = −6.7, P < 0.001). Management All the pa (...truncated)