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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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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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Corresponding Author: Mitsuyo Kinjo, MD, MPH, Department of Medicine, Okinawa Chubu Hospital, 281 Miyasato, Uruma 9042293, Japan (firstname.lastname@example.org).
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.
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