Pruritic Rash and Diarrhea | Dermatology | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

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

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.

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

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.

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

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
1.
Savvidou  S .  Pellagra: a non-eradicated old disease.   Clin Pract. 2014;4(1):637. doi:10.4081/cp.2014.637PubMedGoogle ScholarCrossref
2.
Karthikeyan  K , Thappa  DM .  Pellagra and skin.   Int J Dermatol. 2002;41(8):476-481. doi:10.1046/j.1365-4362.2002.01551.xPubMedGoogle ScholarCrossref
3.
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:10.1155/2012/302875PubMedGoogle Scholar
4.
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/NEJMcps1212211PubMedGoogle ScholarCrossref
5.
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.2011.05.001PubMedGoogle ScholarCrossref
6.
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.2004.05.008PubMedGoogle ScholarCrossref
7.
de Oliveira Alves  A , Bortolato  T , Bernardes Filho  F .  Pellagra.   J Emerg Med. 2018;54(2):238-240. doi:10.1016/j.jemermed.2017.10.010PubMedGoogle ScholarCrossref
8.
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.12090209PubMedGoogle Scholar
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close