Pellagra in Complex Clinical Settings: A Case Involving Bariatric Surgery, Whipple Procedure, and Alcohol Use Disorder.

Pellagra is a disease of niacin (vitamin B3) deficiency and is classically characterized by the triad of diarrhea, dermatitis, and dementia, and has the potential to cause death. Pellagra can be caused by either insufficient dietary intake or dysfunctional utilization of niacin. Because niacin can be found in nearly every food group (meat, dairy, vegetables, grains, etc.), deficiency is rarely seen in resource-rich countries where food scarcity is less prevalent. In this case, a 50-year-old woman presented to the emergency department with abdominal pain, watery diarrhea, altered mental status, altered taste, and a scaly rash on her upper extremities and perioral region. Her medical history was notable for alcohol use disorder, obesity previously treated with a gastric bypass, and chronic pancreatitis managed by a prior Whipple procedure. On examination, she was alert and oriented, with notable glossitis, cheilitis, excoriated rashes on the flexor surfaces of her hands, and 2+ pitting edema in both her upper and lower extremities. Laboratory findings were significant for megaloblastic anemia with a hemoglobin of 10.6 g/dL, hypoalbuminemia of 2.4 g/dL, transaminitis with alanine aminotransferase (ALT) of 60 units/L, and aspartate aminotransferase (AST) of 105 units/L, and deficiencies in niacin and vitamin D at less than 20 ng/mL and 12 ng/mL, respectively. Given her clinical presentation, laboratory findings, and significant surgical and medical history, the patient was diagnosed with pellagra. Treatment was initiated with electrolyte and vitamin supplementation as well as furosemide to address the anasarca. The patient initially showed improvement with vitamin supplementation, and the edema in her upper extremities began to decrease. However, the patient developed acute changes in mental status, and a stroke alert was enacted. Although MRI and CT imaging revealed no acute intracranial abnormalities, elevated lactic acid levels (5.2 mmol/L) raised suspicion for seizure activity. She became encephalopathic and obtunded and was subsequently transferred to the ICU for further evaluation and management. Despite appropriate interventions, she continued to decompensate in the setting of hospital-acquired bacteremia and septic shock. She ultimately passed away one month later. Although pellagra is a rare disease in the United States, it should be considered in patients presenting with the multi-system findings as seen in our patient. Bariatric and Whipple surgery patients are at particular risk for nutrient deficiencies, especially when compounded by alcohol use. It is crucial to educate patients who undergo bariatric or Whipple surgery on the importance of adhering to nutritional supplementation and limiting alcohol use, as these patients have the ideal conditions required for the development of pellagra. Niacin supplementation is the standard for treatment, and early intervention is key to preventing further complications and death.