Two cases of pellagra. The 4D disease--forgotten but fatal]

Epidemics of pellagra, the dreaded “4D disease”, still occur in wars and disasters. It also remains endemic in parts of the world, even though prevention with nicotinic acid is known to be remarkably efficient. Elsewhere, there are sporadic cases. Timely diagnosis and treatment are essential to avoid permanent functional impairment and even death. Two cases are presented here.A 31-year-old autistic woman with a history of eating disorder suffered from gastrointestinal and neurological symtoms. Upon examination erythematous, weeping, thickened and desquamating skin lesions were found on sun-exposed areas. The patient’s diet consisted mostly of Greek salad. A 44-year-old woman suffered from disabling weakness of the lower limbs after a period of weight loss and high alcohol consumption. Cobalamine and folic acid supplementation was ineffective. Dermatological examination revealed pellagrous skin lesions on the back of her hands. Both patients responded rapidly to nicotinic acid replacement therapy.