Pellagrous encephalopathy presenting as alcohol withdrawal delirium: A case series and literature review
Open accessAbstract
BACKGROUND: Alcohol withdrawal delirium (AWD) is associated with significant morbidity and mortality. Pellagra (niacin deficiency) can be a cause of delirium during alcohol withdrawal that may often be overlooked. OBJECTIVES: We present a three-patient case series of pellagrous encephalopathy (delirium due to pellagra) presenting as AWD. METHODS: We provide a brief review of pellagra's history, data on pellagra's epidemiology, and discuss pellagra's various manifestations, particularly as related to alcohol withdrawal. We conclude by providing a review of existing guidelines on the management of alcohol withdrawal, highlighting that they do not include pellagrous encephalopathy in the differential diagnosis for AWD. RESULTS: Though pellagra has been historically described as the triad of dementia, dermatitis, and diarrhea, it seldom presents with all three findings. The neurocognitive disturbance associated with pellagra is better characterized by delirium rather than dementia, and pellagra may present as an isolated delirium without any other aspects of the triad. DISCUSSION: Although endemic pellagra is virtually eradicated in Western countries, it continues to present as pellagrous encephalopathy in patients with risk factors for malnutrition such as chronic alcohol intake, homelessness, or AIDS. It may often be mistaken for AWD. Whenever pellagra is suspected, treatment with oral nicotinamide (100 mg three times daily for 3-4 weeks) prior to laboratory confirmation is recommended as an inexpensive, safe, and potentially life-saving intervention.
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Long-term niacin deficiency can lead to neurological symptoms, including depression and loss of memory, which attenuate or disappear following niacin intake.
“Long-term niacin (vitamin B3) deficiency can lead to neurological symptoms, including depression and loss of memory [102]. These symptoms attenuate or disappear following niacin intake, confirming its role in the brain and nervous system [143].”
From Vitamins and Minerals for Energy, Fatigue and Cognition: A Narrative Review of the Biochemical and Clinical Evidence (2020) · cites this paper as [143]
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Beck, B., Smith, F. A., & Stern, T. A. (2024) · Elsevier eBooks · doi:10.1016/b978-0-443-11844-9.00021-7
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Damodaran, D., Rajagopalan, R., Vethanayagam, M., & Kandasamy, R. (2024) · International Journal of Research in Dermatology · doi:10.18203/issn.2455-4529.intjresdermatol20243877
Phenobarbital-Induced Pellagra: A Diagnosis Not to Overlook
Berrim, K., Lakhoua, G., Charfi, O., Aouinti, I., Daghfous, R., & Aïdli, S. E. (2025) · Dermatitis · doi:10.1089/derm.2025.0035
Carrara, N., Sasso, G. D., Addis, A., Domanico, A., Preto, N., Saler, E., Pievani, T., Artioli, G., & Scaggion, C. (2025) · International Journal of Osteoarchaeology · doi:10.1002/oa.3400
Pellagra encephalopathy in Huntington disease: An autopsy case
Moriyoshi, H., 早川, 雄., Akagi, A., Riku, Y., Sone, J., Miyahara, H., Katsuno, M., Nakanishi, H., & Iwasaki, Y. (2026) · Journal of Neuropathology & Experimental Neurology · doi:10.1093/jnen/nlag109
- Authors
- Oldham, M. A., & Ivkovic, A.
- Affiliations
- Boston University (US)
- Venue
- Addiction Science & Clinical Practice
- Published
- 2012-07-06
- Volume
- 7
- Issue
- 1
- Pages
- 12-12
- ISSN
- 1940-0632 (ISSN-L)
- 1940-0640
- PMC
- PMC3542555
- OpenAlex
- W2110630514
- Cited by
- 56
- References
- 61
- Citations by year
- 2026: 3 · 2025: 3 · 2024: 4 · 2023: 5 · 2022: 8 · 2021: 4 · 2020: 6 · 2019: 6 · 2017: 2 · 2016: 4 · 2015: 2 · 2014: 7 · 2013: 2
- FWCI
- 2.30
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Addiction Science & Clinical Practice (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Funders
- School of Medicine, Boston University
- Topics
- Health Sciences › Medicine › Neurology › Alcoholism and Thiamine Deficiency
- Health Sciences › Medicine › Pathology and Forensic Medicine › Alcohol Consumption and Health Effects
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Electrolyte and hormonal disorders
- Keywords
- pellagra, niacin deficiency, delirium tremens, delirium, nicotinamide, differential diagnosis, malnutrition, chronic alcohol consumption, homelessness, AIDS
- MeSH terms
- Alcohol Withdrawal Delirium, Alcoholism, Brain Diseases, Diagnosis, Differential, Female, Ill-Housed Persons, Humans, Male, Middle Aged, Pellagra, Risk Factors, Practice Guidelines as Topic, Dietary Supplements
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