Journal of Clinical Images and Medical Case Reports

ISSN 2766-7820
Clinical Image - Open Access, Volume 4

Pellagra: A forgotten sporadic clinical entity in primary health care

Shambhu Khanal1*; Sushmita Bhandari2; Savita Aryal3; Buddha Rayamajhi4

1Department of Internal Medicine, Institute of Medicine Tribhuvan University, Nepal.

2Department of Dermatology, Fatima Jinnah Medical University, Lahore, Pakistan.

3Department of Otorhinolaryngology, Universal College of Medical sciences, Nepal.

4Department of Dermatology, Institute of Medicine Tribhuvan University, Nepal.

*Corresponding Author : Shambhu Khanal
Department of Internal Medicine, Institute of Medicine Tribhuvan University, Nepal.
Email: [email protected]

Received : Jun 08, 2023

Accepted : Jun 30, 2023

Published : Jul 07, 2023

Archived :

Copyright : © Khanal S (2023).

Keywords: Pellagra; Diarrhoea; Casal’s necklace.

Citation: Khanal S, Bhandari S, Aryal S, Rayamajhi B. Pellagra: A forgotten sporadic clinical entity in primary health care. J Clin Images Med Case Rep. 2023; 4(7): 2489.


A 45- year- old male from an urban community, laborer, heavy alcohol consumer, exclusively on rice diet presented to outpatient department in primary health care centre with chronic diarrhea for three months. He was treated multiple times with antibiotics with no improvement. There was no family history of similar illness. He had normal vital signs and mental state. On general examination, he had typical sharply marginated symmetrical scaly hyperpigmented plaques in sun exposed areas of his forearms and hands and necklace pattern of erythematous scaly plaque around the neck popularly known as Casal’s necklace as described in Figure 1. The clinical background and dermatological pattern was sufficient enough to initiate treatment of pellagra with oral Niacin 300 mg daily and vitamin B complex. He had dramatic improvement in his episodes of diarrhea. He had-gradual recovery in dermatitis.

Clinical image description

Pellagra is a sporadic and often ignored clinical entity which is classically described as constellation of dermatitis, diarrhea, dementia and death [1]. Niacin deficiency is a clinical consideration in chronic alcoholics, malnourished individuals, malabsorptive disorders, exclusive maize diet and patients on hemodialysis [2,3]. Being a fatal but treatable nutritional disorder, the high index of suspicion can identify the disease early in community. Only 15-20 mg of niacin in diet daily is sufficient to prevent pellagra in all age groups. The daily recommended dose for treatment of pellagra is 300 mg of nicotinamide in divided doses. Besides traditional concept of pellagra in maize eating population, pellagra can be seen in exclusively rice eating population as seen in Bhutanese refugees from Nepal in 1994. Fortified blended diet with niacin almost eradicate the disease [3].

Figure 1: Pellagra dermatitis on dorsum of forearms and Casal’s necklace pattern pellagra dermatitis on neck.


Acknowledgements: We would like to thank everyone involved during treatment

Conflict of interest: No conflict of interest

Funding : The work has no funding source.

Ethical approval: The consent from the patient deemed to be enough.

Consent: Written informed consent taken from the patient