Abstract
BACKGROUND: Classical triad of diarrhea, dermatitis, and dementia is a relatively uncommon finding in pellagra. , a more frequent association of pellagra is being seen with depression, delusion, and delirium. Biochemical chronology is hypothesized for sequential manifestations of neuropsychiatric symptoms of pellagra. AIM-: To illustrate the sequential psychopathology in pellagra and discuss the underlying biochemical hypothesis. METHODS-: We describe three young adults with alcohol dependence syndrome who had symptoms of depression and photosensitive dermatitis progressing to solitary delusion in less than a year and finally manifesting to delirium at the time of presentation. Dermatology consultation was notable for the diagnosis of pellagra in all three cases. Routine biochemical, hematology, and imaging were within normal limits. All three cases responded rapidly with niacin supplementation and very low doses of benzodiazepines associated with around 80% drop in the scores of Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) within 5 days of admission. Due to the unaffordability of investigations eg. 24-hour urine tests for N-methyl nicotinamide, the reliance on clinical improvement considered as the primary outcome of improvement in psychopathology. CONCLUSION-: It is crucial to recognize the subtle psychiatric manifestations of Pellagra. Rapid response to niacin supplementation in the case series supports the psychiatric manifestations and requires scientific inquiry in controlled studies. The role of tryptophan metabolism and its shuttling between serotonin and kynurenine pathway in sequential manifestation into depression, delusion, and delirium support biochemical etiological model of pellagra.