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y 30 (2008) 581–584

General Hospital Psychiatr

Case Reports

Rapid resolution of delusional parasitosis in pellagra with niacinaugmentation therapy

Ravi Prakash, M.B.B.S., D.P.M. (Std)a,⁎, Sachin Gandotra, M.B.B.S., D.P.M., M.D.a,Lokesh Kumar Singh, M.B.B.S., D.P.M., M.D. (Std)a, Basudeb Das, M.B.B.S., M.D.a,

Anuja Lakra, M.B.B.S., M.D. (Pathology) (Std)baCentral Institute of Psychiatry, Ranchi, India 834006

bDepartment of Pathology, Rajendra Institute of Medical Sciences, Ranchi, India 834009

Received 1 March 2008; accepted 30 April 2008

Abstract

Pellagra is associated with low levels of vitamin B3 (niacin) and/or tryptophan and often involves other other B vitamins. Since the timeGasper Casal first described the disease in 1972, it was observed that the patients with pellagra were all poor, subsisted mainly on maize, andrarely ate fresh meat. Subsequent occurrences have been in the form of epidemic outbreaks, consequent to either introduction to maize as amajor food or increased consumption of other niacin-deficient diets like Jowar (Sorgum vulgare). The virtual disappearance of pellagra as anendemic health problem in recent years can be attributed to a rise in the standard of living of farmers and diversification of the diet globally.The clinical picture is a combination of multisystem alterations typically involving gastrointestinal, skin and central nervous systemabnormalities. The cardinal manifestations have been popularly known as the three D's, which are dementia, dermatitis and diarrhea.Psychiatric manifestations are fairly common but are easily overlooked due to their non specific nature. These are commonly seen asirritability, poor concentration, anxiety, fatigue, restlessness, apathy and depression. The occurence of psychosis in pellagra is an uncommonfinding, which is usually seen in advanced stages of pellagroid encephalopathy, commonly found in chronic alcoholics. Delusional parasitosishas been also reported in this condition, although the association is still controversial. We report a case of pellagra manifesting withdelusional parasitosis in a man whose delusion resolved rapidly after he started niacin-augmentation therapy. This case may provide clues tothe biological underpinnings of delusional parasitosis as well as niacin treatment as treatment option in similar cases.© 2008 Elsevier Inc. All rights reserved.

Keywords: Pellagra; Delusional parasitosis; Niacin augmentation

Pellagra is a deficiency disease associated with low levelsof vitamin B3 (niacin) and/or tryptophan and often involvingother B vitamins. Since the time Gasper Casal first describedthe disease in 1972, it was observed that patients withpellagra are all poor, subsist mainly on maize and rarely eatfresh meat. Subsequent occurrences have been in the form ofepidemic outbreaks, consequent to either introduction tomaize as a major food or increased consumption of otherniacin-deficient diets like jowar (Sorgum vulgare) [1]. Thevirtual disappearance of pellagra as an endemic healthproblem in recent years can be attributed mainly to a general

⁎ Corresponding author.E-mail address: drravi2121@gmail.com (R. Prakash).

0163-8343/$ – see front matter © 2008 Elsevier Inc. All rights reserved.doi:10.1016/j.genhosppsych.2008.04.011

rise in the standard of living of small farmers, accompaniedby greater diversification of the diet [1–3]. The clinicalpicture is a combination of multisystem alterations typicallyinvolving gastrointestinal, skin and central nervous systemabnormalities. The cardinal manifestations have beenpopularly known as the three D's which are dementia,dermatitis and diarrhea [1,2]. Psychiatric manifestations arefairly common but are easily overlooked due to theirnonspecific nature. These are commonly seen as irritability,poor concentration, anxiety, fatigue, restlessness, apathy anddepression. The occurrence of psychosis in pellagra is anuncommon finding, which is usually seen in advanced stagesof pellagroid encephalopathy, commonly found in chronicalcoholics [4]. Psychiatric symptoms are often associatedwith other features of encephalopathy, including confusion,

Fig. 1. Scaly lesions on forehead and face. Fig. 3. Icthyotic and desquamative lesions on dorsum of both feet and onboth tibial regions.

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coma and death. We present a rare case of pellagra manifes-ting with delusional parasitosis.

Mr. B/S is a 45-year-old male, of low socioeconomicstatus, hailing from a rural background, who presented tothe hospital OPD with the complaints of suspiciousnesstowards family members, muttering and smiling to self, andcomplaining of insects in his abdomen. A detailed mentalstatus examination on the day of presentation revealed anapathetic patient, retarded psychomotor activity, slowspeech of soft quality, dysphoric affect, delusion ofparasitosis and poor insight. He did not reveal anyperceptual abnormality. A detailed elaboration of hisdelusion of parasitosis revealed that he was very sure ofhaving caterpillars of 5–6 in. in length inside his abdomen,which entered his body by his foot and traveled all the wayto his stomach. He expressed repeatedly that he could feelthe crawling of these caterpillars. The main reason of hissurety for this infestation was that he was becoming weaker

Fig. 2. Icthyotic skin changes in exposed parts of dorsum of both hands.

day by day and this was all due to the worms sucking hisblood from his intestine. He also had ideas of hopelessnessand helplessness secondary to the parasitosis phenomenonin his body. His cognitive functions showed impairments inthe Mini Mental Status Examination (MMSE), with a scoreof 23. He had impairments in recent recall and following ofwritten commands as well as serial subtraction. Thephysical examination revealed scaly lesions on his skin inthe sun-exposed parts, most prominent being on the dorsumof his both hands, both feet, forehead and below the neck(Figs. 1–3). The neck lesions were very similar to thedescription of Casal necklace in the literature. He also hadmild anemia. A physical history revealed that he washaving frequent diarrhea in the past couple of months. Thepatient was subjected to a detailed investigation, includinghis hemogram, liver function tests, kidney function tests,lipid profile, random and post prandial blood sugar, Na,K electrolytes, thyroid function tests, electroencephalo-gram, CT scan of brain, VDRL for syphilis, ELISA for HIVand tuberculosis, chest X-ray in PAview and stool for occultblood. The test results pointed towards his poor nutritionalstate. His hemoglobin was 10.2 mg/dl. His mean corpuscularvolume was 80 fl and mean corpuscular hemoglobin was25 pg. His albumin concentration was also slightly decreased(3.4 g/dl). His electroencephalogram record showed anonspecific slowing in the alpha range of frequency 7.5–8 Hz. The rest of the investigations including CT scan did notreveal any abnormalities. On the basis of the mental statusexamination and history, he was given a working diagnosis ofunspecified schizophrenia, which was diagnosed by using theICD-10 criteria. He was also given only a provisionaldiagnosis of pellagra due to lack of confirmatory evidencessuch as serum niacin estimation or skin biopsy because oflack of laboratory ability or dermatologic consultation. Hewas subsequently started on injections of haloperidol 10 mgim bid and phenergan 50 mg im bid, and B-Complex capsule

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containing niacin 50mg/day in qid doses. The injections werestopped after 2 days and he was switched to oral haloperidol15–20 mg/day and trihexyphenidyl 2 mg/day. Within 4 days,he stopped complaining of worms in his intestine and startedshowing his dysphoria and ideas of hopelessness andhelplessness. When confronted about his ideas about parasiteinfestation, he would say that he did not know what hadhappened to him to think of such thing. His skin lesionsstarted showing improvement after 1 week and progressivelyresolved by the end of 2 weeks, when he was discharged.He never complained of any gastrointestinal symptomsover his stay in the hospital. He did not show up for follow-up appointments.

Historically, pellagra has been documented in the formof outbreaks. The disease occurs mostly among poorergroups whose diet consists mainly of the cheapest availablefood, maize, supplemented with salt pork, lard andmolasses [1]. Sporadic cases continue to be seen globallyand are associated with monotonous diets of untreatedmaize, food faddism, tuberculosis treatment, malabsorptionstates and alcoholism [4–8]. Our patient seems to besimilar to other sporadic cases where pellagra occurredsecondary to undernutrition, which was probably pro-foundly deficient for niacin [9]. Factors in our patient insupporting this etiology include his low socioeconomicstatus, his blood picture revealing anemia (hemoglo-bin=10.2 mg/dl), low mean corpuscular volume and lowmean corpuscular hemoglobin concentration and hismodestly low albumin concentration (3.4 g/dl). This is acommon cause of vitamin deficiency states in the lowsocioeconomic group in our country. As mentioned earlier,pellagra has become so uncommon in developed as well asdeveloping countries that the current incidence in theseparts of the world is unknown. Due to such a lowprevalence, the psychiatric states in this disorder areinadequately studied. Cognitive impairments are commonin this disorder, so much so that they have been included inthe cardinal features of this disease (‘dementia’ in the threeD's). These generally include impaired concentration,memory impairments and, in severe cases (pellagraoidencephalopathy), confusion, delirium and coma [2]. In ourpatient, the cognitive impairments were not very prominentalthough he did show deficits in MMSE (a score of 23).This impairment could have been due to the cerebralinvolvement, as further reflected by the nonspecific slowingof the background rhythm in the alpha range (7.5–8 Hz).However, these findings cannot be overemphasized giventhat they are known to be associated with advancing age.

Although knowledge of pellagra is often deficient inpsychiatric settings in view of its low incidence anduncommon psychiatric presentation, it may be important inproviding clues for biological underpinnings of psychoticstates in general and of delusional parasitosis in particular.The psychotic symptoms due to alcoholism and drugs aremyriad and are difficult to correlate with niacin deficiencyalone keeping in view other deficiency states found

comorbidly in such conditions. However, earlier scientificliterature does reveal that niacin deficiency has beenassociated with three main types of psychiatric manifesta-tions, which are (a) schizophreniform, (b) manic depressivetypes and (c) anxiety and depressive disorders [6]. Schizo-phreniform manifestations include auditory hallucinationsand persecutory delusions. Occurrence of delusory para-sitosis is an extremely rare phenomenon in this deficiencystate. This usually develops secondary to the patients'complaints of pruritus and paraesthesias due to pellagra skinlesions. This is the reason why patients with such complaintsrefer to a dermatologist rather than to a psychiatrist [7].However, our patient presented with complaints of delu-sional parasitosis which was independent of skin lesions andwhich he attributed as the reason for all of his physicalproblems. Such a presentation has not been reported in theliterature to the best of our knowledge. It seems that suchpatients are prone to develop delusory parasitic ideasindependent of the skin lesions.

Given that this patient was treated with both niacin andantipsychotic medication, it is unclear which treatment (orthe combination of treatments) reversed his psychosis.However, parasitosis is known for its resistance toantipsychotic treatment and such a rapid resolution of anydelusion. The literature is deficient regarding any effect ofniacin on improvement of parasitosis. The resolution of thepatient's skin lesions also supports the efficacy of pellagra.The exact relation between nicotinic acid deficiency andpathogenesis of delusions or hallucinations is not clear.However, it is likely to involve subtle neuronal insult.Postmortem examination has revealed chromatolysis in suchpatients [10]. Indirect evidences suggest that niacin antag-onism is associated with evident neuroglial (especiallyastrocytic) degeneration and subsequent disturbances insignal transmission across neurons [11]. Other studies alsopoint towards an association of niacin abnormalities withpsychosis. A recent study showed abnormal niacin sensitiv-ity in schizophrenia patients as evidenced by attenuation ofthe flush response to niacin in schizophrenia. However, thereis still an ongoing debate whether this response is due toaltered pharmacological sensitivity to niacin or an inade-quate cutaneous vasodilatory response to the stimulus [12].Earlier studies have even attempted to use niacin as anaugmenting agent for the treatment of schizophrenia withmixed results [13,14]. In a placebo-controlled comparativestudy by Ramsay et al. [15], it was found that, while nosignificant differences were seen in total BPRS scores priorto commencement of the clinical trial, statistically significantimprovement in ‘emotional withdrawal’ was seen only withnicotinamide, and not with placebo. Regarding the dosage ofniacin, we administered as per the WHO recommended dosewhich is 300 mg of nicotinamide in divided doses, to becontinued for 2–3 weeks [3].

To conclude, our findings suggest in patients withdelusional parasitosis, pellagra should be considered asan important differential diagnosis especially in those with

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typical skin lesions as presented in our case. In such cases,especially with prominence of other features of pellagra,niacin augmentation can be tried and close observation fordramatic improvement of symptoms is warranted.

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