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DR SUBHASISH DEB
Burdwan Medical College and Hospital
Department of General Medicine
CASE 1
A 42 year old woman was admitted to hospital with
a one month history of progressive forgetfulness,
irritability and confusion. There was no history of
tremor or confabulation. There was no history of
fever, headache, neck-ache or neck stiffness.
Further inquiry revealed she had developed rash
around her neck and in the distal parts of all four
limbs a month prior to the onset of the altered
mental status. The guardians also reported that the
patient had had diarrhea which was watery and had
lasted a week prior to admission. There was no
history of vomiting. She was on Cat 1 for the past 4
months.
Diagnosis?
PELLAGRA (ISONIAZID INDUCED)
Pellagra is due to B3 (niacin) deficiency
Isoniazid induced pellagra is caused by deficiency
of B3 DUE TO a deficiency of B6 (thiamine)
The picture : Casal’s necklace
B6
CAUSES
1. Deficiency of niacin (maize eating population)
2. Deficiency of tryptophan
Decreased intake (meat, fish)
Lucine (inhibits QRPT enzyme)
B6 deficiency (needed by kynunreninase
enzyme)
3. Carcinoid syndrome (conversion to serotonin)
4. Factors causing decreased absorption – Crohn’s
disease, Gasteroenterostomy, chronic alcoholism,
Hartnup’s disease
FEATURES:
4 D’s
Dermatitis
Diarrhoea
Dementia
Death
Others-
Glossitis, loss of appetite, generalized weakness ,
vomiting, abdominal pain.
DUE TO B6 DEFICIENCY:
Microcytic Hypochromic anemia (B6 reqired by
delta ALA – 1st enzyme of heme sys)
Seizures :
glutamate
glutamate decarboxylase B6
GABA
Hyperactivity of neurons due to excess of glutamate
Homocysteinuria :
Cystathianone B synthase requires B6 (PLP) to convert
homocysteine to cystathione – increased CVA chances
TREATMENT
Always give Pyridoxine with isoniazid
B3 deficincy treated by:
oral nicotinamide (niacin) 100-200mg TDS x 5days
Adverse effects of niacin: FLUSHING
Due to tachyphylaxsis
Premedication with ASPIRIN
Niacin combined with
LAROPIPRANT a
prostaglandin D2 receptor 1
antagonist
CASE 2
A 58 year old woman came with a chief
complaint of syncope. She also had low
grade fever 38C.
Her 12 lead ecg showed..
BRUGADA SYNDROME
First described in 1992 by Pedro and Josepg
Brugada
Associated with sudden cardiac death
ST depression
CASE 3
Papules extending to form a yellow–red plaque
covered with telangiectatic vessels on the
patient's forearm. CBG 330. ???
NECROBIOSIS LIPOIDICA
DIABETICORUM
Necrobiosis lipoidica was first described by
Oppenheim in 1929 as a chronic granulomatous
dermatitis of unknown cause.
female:male ratio of 3:1