Pellagra

What is pellagra

Pellagra is a curable nutritional deficiency disease which develops through a severe deficiency of vitamin B3 (niacin).

Pellagra can be of two types:

• Primary – this is when the body has a severely low (or no) intake of vitamin B3 (niacin) over a long period due to a low intake in the diet
• Secondary – this is when the intake of vitamin B3 (niacin) in the diet is not absorbed due to a variety of factors including many disease, drugs and other conditions

Facts about pellagra

• Pellagra is basically a preventable disease
• Vitamin B3 (niacin) is the vitamin that prevents this disease
• The amino acid tryptophan is also required to prevent pellagra as it synthesises vitamin B3 (niacin) for the body to be able to use it properly
• People who are chronic alcoholics very often develop pellagra
• People with anorexia nervosa can develop pellagra
• Pellagra is still very common in countries where corn (or maize) is the staple food and this means people there do not get enough vitamin B3 (niacin) through this type of diet

Symptoms of pellagra

The early symptoms of the vitamin B3 (niacin) deficiency condition are:

• Dermatitis
• Diarrhoea
• Headache
• Lethargy
• Loss of appetite
• Nausea
• Psychological – agitation, anxiety and depression
• Stomach cramps
• Vomiting
• Weakness

Later-stage symptoms are:

• Confusion
• Dementia-like symptoms

The final result of pellagra is death due to multi-organ failure.

Causes of pellagra

Pellagra is a deficiency disease (either a deficiency of vitamin B3 (niacin) and/or tryptophan), but there are two types of this condition with two different causes of the deficiency:

Primary pellagra

This type of pellagra occurs when there is a severely low (or no) intake of foods high in vitamin B3 (niacin) over a long period and this causes the deficiency symptoms associated with pellagra.

Secondary pellagra

This type of pellagra is caused when the intake of vitamin B3 (niacin) in the diet is not absorbed properly and this is due to a variety of factors including many other health condition and certain medications.

Prevention of pellagra

Non-preventable risk factors

Pellagra may be unpreventable in certain circumstances:

• People with certain conditions – people with certain health conditions (diabetes) that affect their body’s ability to absorb the vitamin B3 (niacin) content in foods eaten may not be able to prevent this from occurring. Your doctor will discuss your options on how to prevent a serious vitamin B3 (niacin) deficiency
• People taking certain medications – people taking certain medications (antibiotics, isoniazid) that affect their body’s ability to absorb the vitamin B3 (niacin) content in foods eaten may not be able to prevent this from occurring. Your doctor will discuss your options on how to prevent a serious vitamin B3 (niacin) deficiency

Preventable risk factors

There are ways to prevent pellagra from occurring.:

• Don’t drink alcohol excessively – excessive amounts of alcohol causes a high excretion of nutrients from the urine and long term alcoholics have a deficiency of not just vitamin B3 (niacin), but also all the nutrients. People with an addiction to alcohol must seek help to prevent not just pellagra, but other health conditions associated with excessive alcohol intake
• Eat a healthy diet – a diet rich in foods high in vitamin B3 (niacin) is essential to prevent a deficiency in this important nutrient. The foods that are rich in vitamin B3 (niacin) are: beef, fish, chicken, nuts
• Take supplements if necessary – people who are in the groups at risk of developing pellagra, may be recommended to take a vitamin B3 (niacin) supplement to prevent deficiency. Usually a vitamin B complex supplement with all the B vitamins will be recommended, because if vitamin B3 (niacin) is deficient in the diet, the other B vitamins may be deficient too. A tryptophan supplement may also be recommended
• Vegetarian / vegan diet – people who are on a strict vegetarian or vegan diet may become more easily deficient in vitamin B3 (niacin) as the foods that contain high levels are chicken, beef and fish

Complications of pellagra

The main complications of pellagra are very serious and this condition can be life-threatening if it is not treated with a dose of vitamin B3 (niacin) supplementation of some form:

Dementia-like symptoms

The most common complication of late-stage pellagra (other than fatality) are dementia symptoms, which can often be confused with Alzheimer’s disease. The person with pellagra can experience severe confusion, delusions and anxiety, which are all symptoms of pellagra, but are also symptoms of dementia and can be easily confused, especially if the person with pellagra is older.

Severe psychological symptoms

Even a moderate deficiency of vitamin B3 (niacin) can cause a whole range of psychological symptoms that may be misdiagnosed as a mental health disorder, but may actually be simply due to a deficiency of vitamin B3 (niacin).

The most common psychological symptoms to occur are:

• Anxiety and
• Depression

People who may be in one of the groups at risk of deficiency should consult with their doctor to have a blood test and confirm or rule out pellagra.

When to see a doctor about pellagra

People who are in any of the groups at risk of deficiency of vitamin B3 (niacin) should consult with their medical doctor in order to have a simple blood test that can diagnose and confirm (or rule out) pellagra.

People who have existing pellagra and who are being treated at home (through supplementation) need to visit their doctor for a check-up after completing the vitamin B3 (niacin) supplements to determine if blood levels have returned to normal and deficiency is no longer present.

Diagnosis of pellagra

Initial diagnosis of pellagra involves the following:

• Medical history of symptoms – the doctor will ask a series of questions about severity and duration of symptoms, including the onset, to determine if there is a risk factor of pellagra
• Physical examination – the doctor will perform a physical examination to determine if there are any obvious physical symptoms of pellagra

Other tests

If the conditions warrant and to confirm diagnosis the following tests are requested:

• Blood test – this will test for blood levels of vitamin B3 (niacin), as well as levels of red and white blood cells and any other factors the doctor deems necessary

Conventional treatment of pellagra

Conventional treatment of pellagra depends on the type of pellagra and the seriousness of the condition:

Primary Pellagra

• Foods rich in vitamin B3 (niacin) – this option will be recommended especially for people with mild to moderate pellagra, usually together with the vitamin B3 (niacin) inject or supplements
• Vitamin B3 (niacin) – for a severe deficiency, vitamin B3 (niacin) is given intravenously to try to top up the levels of this vitamin in the body and reduce symptoms. The vitamin B3 (niacin) is given intravenously to prevent it from going through the stomach and to enable more of it to be absorbed into the blood stream more quickly. If the deficiency is mild to moderate, then a supplement will be recommended with all the B vitamins and possibly tryptophan too

Secondary Pellagra

• Vitamin B3 (niacin) – in this type of pellagra, it is necessary to give the vitamin B3 (niacin) intravenously to try to top up the blood levels in the body very quickly and reduce symptoms. The vitamin B3 (niacin) is given intravenously to prevent it from going through the stomach and to enable more of it to be absorbed into the blood stream more quickly

Alternative / complementary treatment of pellagra

Serious pellagra (especially secondary pellagra) should only be diagnosed and treated by a medical doctor who can administer vitamin B3 (niacin) and any other nutrients intravenously. The recommendations below are for people who have a mild deficiency in vitamin B3 and need to top up their levels back to normal.

Herbs

There are no herbs that are recommended to be used for people with pellagra.

Vitamins

Treatment of pellagra involves the following:

• Vitamin B3 (niacin) – supplementation with vitamin B3 (niacin) is recommended to help increase this nutrient in the bloodstream, to reduce symptoms and prevent any possible complications and late stage symptoms
• Vitamin B complex – in order to support the absorption of the vitamin B3 (niacin), it should be supplemented together with the other B vitamins in a B vitamin complex

Minerals

There are no minerals that are recommended to be used for people with pellagra.

Other nutrients

There is one other nutrient which is recommended to be taken along with the vitamin B3 (niacin):

• Tryptophan – the amino acid tryptophan is required to enable the body to use vitamin B3 (niacin) properly and in fact, a deficiency of tryptophan can make pellagra worse so is recommended

Dietary modifications

There are some dietary modifications which may be useful in preventing pellagra or reducing pellagra symptoms (along with the other recommendations here):

• Eat more foods rich in tryptophan – these foods should be incorporated into the diet. The foods highest in tryptophan are: freshly cooked turkey, bananas, beef, cottage cheese, lentils, peanuts, pumpkin seeds, sesame seeds, soy beans
• Eat more foods rich in vitamin B3 – these foods should be incorporated into the diet. The foods highest in vitamin B3 (niacin) are: almonds, beef, chicken, legumes, mackerel, peanuts, salmon, sardines, sunflower seeds

Lifestyle modifications

There are no lifestyle modifications that are recommended to be used for people with pellagra.

Alternative treatments

There are no alternative treatments that are recommended to be used for people with pellagra.

Always ensure that you notify your medical practitioner of any supplements that you want to take – it may interfere with other medication or conditions you have. Confirm with your doctor it is safe to take before you try it.

Living with pellagra

Self care strategies

There are a number of strategies which are recommended to help deal with pellagra:

• Eat foods rich in tryptophan – there are a number of foods rich in tryptophan which should be included in the diet: freshly cooked turkey, bananas, beef, cottage cheese, lentils, peanuts, pumpkin seeds, sesame seeds, soy beans
• Eat foods rich in vitamin B3 (niacin) – there are a number of foods rich in vitamin B3 (niacin) which should be included in the diet: almonds, beef, chicken, legumes, mackerel, peanuts, salmon, sardines, sunflower seeds
• Regular blood tests – you need to have your blood levels of vitamin B3 (niacin) monitored to ensure that you do not become more deficient and develop further symptoms of pellagra after supplementation (or intravenous injection)
• Take vitamin B3 (niacin) supplements – your doctor will recommend supplements to boost your body’s levels of vitamin B3 (niacin) and decrease risk of deficiency
• Vitamin B3 (niacin) intravenously – your doctor may also give you a vitamin B3 (niacin) injection if you have a certain medical condition or are taking certain medications long term that warrant treatment in this way

Caring for someone with pellagra

Partner

There are some useful strategies you can use to help your partner if they have pellagra:

• Doctor check-ups – if your partner needs you, you can go with them to the doctor check-ups to monitor their blood levels of vitamin B3 (niacin) as the doctor may also provide intravenous injections if necessary to avoid further deficiency and deterioration of symptoms
• Foods rich in tryptophan – you should ensure your partner includes a number of foods rich in tryptophan in their diet: freshly cooked turkey, bananas, beef, cottage cheese, lentils, peanuts, pumpkin seeds, sesame seeds, soy beans
• Foods rich in vitamin B3 (niacin) – you should ensure your partner includes a number of foods rich in vitamin B3 (niacin) in their diet: almonds, beef, chicken, legumes, mackerel, peanuts, salmon, sardines, sunflower seeds
• Support and encouragement – your partner will benefit if you provide some words of support and encouragement to your partner, especially if their condition is caused by secondary pellagra as this can be difficult to prevent

Friends

There are some useful strategies you can use to help your friend if they have pellagra:

• Support and encouragement – while you may not be able to physically do anything for your friend to prevent their pellagra symptoms, you can provide support and encouragement as a friend, which is beneficial

Parents

There are some useful strategies you can use to help your child if they have pellagra:

• Doctor check-ups – ensure you take your child to see their doctor (or paediatrician) to monitor their blood levels of vitamin B3 (niacin) and to provide intravenous injections if necessary to avoid further deficiency and deterioration of symptoms
• Foods rich in tryptophan – you should include a number of foods rich in tryptophan in your child’s diet: freshly cooked turkey, bananas, beef, cottage cheese, lentils, peanuts, pumpkin seeds, sesame seeds, soy beans
• Foods rich in vitamin B3 (niacin) – you should include a number of foods rich in vitamin B3 (niacin) in your child’s diet: almonds, beef, chicken, legumes, mackerel, peanuts, salmon, sardines, sunflower seeds

References

• uzina R, Gregurić I, Brodarec A, Jusić M, Horvat A. Pellagra in Istria, Yugoslavia. Am J Clin Nutr. 1967 Aug;20(8):888-96
• Cook CC, Hallwood PM, Thomson AD. B Vitamin deficiency and neuropsychiatric syndromes in alcohol misuse. Alcohol Alcohol. 1998 Jul-Aug;33(4):317-36
• Ishii N, Nishihara Y. Pellagra among chronic alcoholics: clinical and pathological study of 20 necropsy cases. J Neurol Neurosurg Psychiatry. 1981 Mar;44(3):209-15
• Klevay LM. Medical examination in nutrition surveys. J Nutr. 2005 May;135(5):1266-7
• Nogueira A, Duarte AF, Magina S, Azevedo F. Pellagra associated with esophageal carcinoma and alcoholism. Dermatol Online J. 2009 May 15;15(5):8
• Osiecki H. The Physicans Handbook of Clininical Nutrition, 6th Edition. Bioconcepts Publishing QLD, 2001
• Park YK, Sempos CT, Barton CN, Vanderveen JE, Yetley EA. Effectiveness of food fortification in the United States: the case of pellagra. Am J Public Health. 2000 May;90(5):727-38
• Prousky JE. Pellagra may be a rare secondary complication of anorexia nervosa: a systematic review of the literature. Altern Med Rev. 2003 May;8(2):180-5
• Seal AJ, Creeke PI, Dibari F, Cheung E, Kyroussis E, Semedo P, van den Briel T. Low and deficient niacin status and pellagra are endemic in postwar Angola. Am J Clin Nutr. 2007 Jan;85(1):218-24
• Tratter R, Jones A. Better Health Through Natural Healing: How to Get Well Without Drugs or Surgery, 2nd Edition. McGraw Hill, 2001
• Williams AC, Ramsden DB. Pellagra: A clue as to why energy failure causes diseases? Med Hypotheses. 2007;69(3):618-28. Epub 2007 Mar 8
• Young SN. The use of diet and dietary components in the study of factors controlling affect in humans: a review. J Psychiatry Neurosci. 1993 Nov;18(5):235-44

Last reviewed and updated: 14 May 2024