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Quiz

Dermatology

Pruritic Rash and Diarrhea

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA

Published Online: March 16, 2021

JAMA Clinical Challenge

Article Information and Disclosures

Hiroyuki Yano, MD¹;

Mitsuyo Kinjo, MD, MPH¹

Author Affiliations

¹Okinawa Chubu Hospital, Uruma, Japan

Read article on JAMA Network

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An 82-year-old woman presented to the emergency department with 2 months of diarrhea and 2 weeks of rash. She had sustained a left radius fracture 6 months prior, which resulted in deconditioning and poor appetite. Her diet consisted of mostly vegetables, and she lost 4 kg (8.8 lb) during this time. Two months prior, she developed postprandial nonbloody diarrhea that occurred 5 times daily. Two weeks prior, a pruritic rash in her extremities emerged. She had no fever, night sweats, or abdominal pain. Past medical history included chronic nondeforming rheumatoid arthritis, hypothyroidism, and colon adenocarcinoma resected 10 years prior. Her medications were prednisolone (1 mg/d) and levothyroxine.

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Pellagra

C. Measure serum niacin level

The key to the correct diagnosis in this patient is the presence of persistent nonbloody diarrhea, rash in sun-exposed areas, and glossitis in an older frail woman with severe malnutrition—features key to diagnosing pellagra, which is characterized by 4 Ds (dermatitis, diarrhea, dementia, and death) if left untreated.¹

Measurement of fecal calprotectin level (choice A) is not indicated in this patient with no findings of inflammatory bowel disease such as fever, abdominal pain, bloody diarrhea, or elevated levels of inflammatory markers. Because skin changes in sun-exposed areas and glossitis are atypical of parasitic infection and this patient had no eosinophilia, checking for fecal ova and parasites (choice B) also is not indicated. Given the patient’s symptoms suggestive of pellagra, measurement of serum niacin level (choice C) would be appropriate. Testing for serum antitissue transglutaminase antibody (choice D), a screening test for celiac disease, is not immediately indicated in this patient, as her rash is not consistent with dermatitis herpetiformis.

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Article Information

Corresponding Author: Mitsuyo Kinjo, MD, MPH, Department of Medicine, Okinawa Chubu Hospital, 281 Miyasato, Uruma 9042293, Japan (kinjomitsuyo@gmail.com).

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient’s daughter for granting permission to publish this information. We also thank Lisa Rucker, MD, MS (Department of General Internal Medicine, Jacobi Medical Center, New York), and Rita McGill, MD, MS (Department of Nephrology, University of Chicago), for English correction of the manuscript.

References

Savvidou S . Pellagra: a non-eradicated old disease. Clin Pract. 2014;4(1):637. doi:10.4081/cp.2014.637 PubMed Google Scholar Crossref

Karthikeyan K , Thappa DM . Pellagra and skin. Int J Dermatol. 2002;41(8):476-481. doi:10.1046/j.1365-4362.2002.01551.x PubMed Google Scholar Crossref

Williams AC , Hill LJ , Ramsden DB . Nicotinamide, NAD(P)(H), and methyl-group homeostasis evolved and became a determinant of ageing diseases: hypotheses and lessons from pellagra. Curr Gerontol Geriatr Res. 2012;2012:302875. doi:10.1155/2012/302875 PubMed Google Scholar

Kapoor R , Saint S , Kapoor JR , Johnson RA , Dhaliwal G . Clinical problem-solving: D is for delay. N Engl J Med. 2014;371(23):2218-2223. doi:10.1056/NEJMcps1212211 PubMed Google Scholar Crossref

Piqué-Duran E , Pérez-Cejudo JA , Cameselle D , et al. Pellagra: a clinical, histopathological, and epidemiological study of 7 cases. Article in Spanish. Actas Dermosifiliogr. 2012;103(1):51-58. doi:10.1016/j.ad.2011.05.001 PubMed Google Scholar Crossref

Monteiro JP , da Cunha DF , Filho DC , et al. Niacin metabolite excretion in alcoholic pellagra and AIDS patients with and without diarrhea. Nutrition. 2004;20(9):778-782. doi:10.1016/j.nut.2004.05.008 PubMed Google Scholar Crossref

de Oliveira Alves A , Bortolato T , Bernardes Filho F . Pellagra. J Emerg Med. 2018;54(2):238-240. doi:10.1016/j.jemermed.2017.10.010 PubMed Google Scholar Crossref

Cavanna AE , Mitchell JW , Williams AC . The neuropsychiatry of pellagra in early American studies. J Neuropsychiatry Clin Neurosci. 2013;25(4):E08. doi:10.1176/appi.neuropsych.12090209 PubMed Google Scholar

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.