Summary: The 45-year-old male patient described in this case report had a classic case of pellagra. The patient was initially brought to a psychiatric hospital because of disorderly behavior. On admission the patient was unable to provide a history so he was given a provisional diagnosis of Psychosis Not Otherwise Specified. Despite having the cardinal symptoms of dermatitis, dementia and (three days after admission) diarrhea it took 20 days to confirm the diagnosis of pellagra. After initiation of appropriate treatment it took about six months for the patient to make a complete recovery.
Case Report – Status on admission.
A 45-year-old male was admitted in April 2011 after being found lying naked in the street talking to himself and cursing passers-by. He was unable to provide his name or home address so no information was available on his history.
On admission his vital signs were normal (temperature 36.5 °C; pulse, 80 bpm; respiratory rate, 20 times/minute; and blood pressure, 125/80 mmHg) and he had normal muscle strength and reflexes. There were no abnormalities in electrolytes, blood counts, blood glucose, lipid profile, or liver or kidney function tests. Urine and stool tests were normal. EKG, EEG and ultrasound of the liver, kidneys, pancreas and spleen found no abnormalities. The sole abnormality on physical examination was that the skin around his eyes and forehead were dark brown to black and his hands and forearms were covered with flaking skin.
Mental status examination on admission found that the patient was conscious but unable to answer questions correctly. He covered his head with a quilt during the examination for no obvious reason. He laughed to himself, manifested inappropriate emotions and appeared to lack insight into his condition. He had difficulty concentrating, had slowed reactions, and got a score of 20 on the Mini-Mental Status Exam (MMSE)—indicating moderate cognitive impairment.