HYPOVITAMINOSIS AND AVITAMINOSIS : PELLAGRA - etiology, pathogenesis, symptoms and course of, recognition, prediction and prevention
Etiology. The absence or low content in food protivopellagricescoe vitamin PP (nicotinic acid or its amide), as well as the absence of certain amino acids (tryptophan).
The pathogenesis. The greatest number of cases occurs in spring and summer. The most significant practical importance is primary or endemic pellagra. Secondary pellagra is called the syndrome adhering to organic diseases of the gastrointestinal tract: stenosis and cancer of the esophagus, ulcers, cancer and syphilis of the stomach, duodenal ulcer, diarrhoea colitis, ulcerative colitis, tuberculosis of intestines, stenosis and cancer of different parts of the intestine and posioperating States. In these cases, pellagra possible and nutrition. Severe organic disease leads to the violation of the suction process protivopellagricescoe vitamin in the gastrointestinal tract or to the violation of his learning.
Symptoms. The characteristic triad: diarrhea, dermatitis, dementia. The earliest symptoms are: violations of the Central nervous system of the character kind of neurasthenia; irritability, insomnia, depression, and then change the mouth and diarrhea. Skin phenomena develop later, when quite pronounced picture of the disease. In some cases, pellagra diarrhea can either be absent or be very small, skin phenomena, on the contrary, can be very bright. Complaints of burning sensation in the mouth and a strong salivation. The oral mucosa and lips, especially the lower lip sharply hyperemic; mucosa of the lips covered with crusts. The tongue is covered with black-brown, hard-to-remove-tinged, sometimes separated by cracks on the field, chess language. The edges and tip of the tongue tunnelling, then the redness goes on the entire surface of the tongue; he seems to be shining as if varnished. Filiform and mushroom-shaped papillae become inflamed and appear as red dots. The epithelium excoriated - naked language, cardinal language. Acute effects gradually subside, pale mucous, papillae atrophy. On the tongue there are sometimes deep furrows. Simultaneously with the change of the language begin persistent diarrhea - 3 - 5 or more times a day. Complaints of flatulence, rumbling and transfusion in the intestines. Diarrhea is gradually replaced by constipation. Complaints of loss of appetite, sometimes ravenous hunger, a feeling of fullness and heaviness in the stomach, belching, heartburn and nausea. In the gastric juice by the low content of free hydrochloric acid, or its complete absence. Suddenly on the skin in the spring or summer appear rapidly growing red spots - pellegrina erythema. Spots are almost always symmetrical, most often localized on the exposed parts of the body: the back of the hands, feet, neck, face, and sometimes on the chest, forearms, shins and even less often on the palms, armpits, genitals - the scrotum, vulva, vagina and anus. Erythematous skin Kirpichnikova color, swollen, tense and clearly separated from the healthy. It is itchy and a little painful. Only erythema of the face, especially in children, occurs with sudden swelling and pain. Often erythema accompanied by the formation of large blisters filled with serous, hemorrhagic, and purulent content. In uncomplicated erythema after a few days starts quite long lasting peeling. After the peeling is observed or intense pigmentation, or complete disappearance of the pigment. Skin changes become atrophic or hypertrophic stage. When atrophy there is a loss of turgor, rudeness and thinning of the skin. The skin is dry, shiny, parametrirovaniya. When hypertrophy is observed hyperkeratosis, thickening of the skin and often dense pigmentation. Typical location hypertrophic lesions on the face: the follicles around the nose extended and made dead in the form of studs masses (pellagroderma folliculare seborrhoica, dissebacia). Hyper keratosis with thick skin pigmentation on bony prominences of the body and on the soles. During a relapse of pellagra can re-appear and skin lesions. In these cases, the process proceeds more slowly. In some cases, there is loss of eyebrows and hair and trophic nail changes. Cardiovascular system: myodegeneration, the expansion of the boundaries of the heart with atony of the heart muscle, the deaf tones, functional murmur at the apex, permanent, long-term decrease in the maximum and minimum blood pressure. Small rapid pulse, lack of fulfillment. Central and peripheral nervous system: at the beginning of the disease, as already mentioned, neurasthenia, then deep dysfunction; noise and tinnitus, taste perversion, severe itching, headaches, shimmering and Central scotoma, pain in the spine and extremities, genitals, feeling of suffocation, opoyasyvaet, numbness, begonia pins and needles, disorders of tactile and pain sensitivity of surface type. Disorders of cutaneous reflexes, especially abdominal. Motor sphere: shaky and unsteady gait, the patient suddenly falls, the weakening of muscle strength, shaking of the head, tongue, hands, feet, hypertension muscles, increased tendon reflexes, paralysis, ptosis, disturbances of accommodation, diplopia, mydriasis, less cramps, anisocoria, small muscular atrophy, immobility and stiffness, as in parkinsonism, tehnicheskie and horiatiki convulsions, loss of coordination, ataxia. A number of these phenomena should be attributed to the affiliate vitamin B1. Psyche: agentive-hallucinatory and depressive syndromes flowing through the exogenous type of reaction. Psychosis does not start: the patient gradually increases causeless hypochondriacal mood, depression, thoughts of suicide, motor restlessness, silence, disorientation in time and space, confusion, sudden excitement. Periods of remission from several days to several months.
Course and complications. Pellagra has a chronic relapsing course with exacerbations and remissions. The exception is acute pellagra, quickly ending in death. In this type of disease is dominated by effects from the Central nervous system. Sudden inculturation start, often with vomiting and severe diarrhea, dizziness, hallucinations, opistotonus, lockjaw, stiffness in limbs, tonic and clinical seizures at the slightest touch to the patient, a sharp increase in tendon reflexes, subfebrile and febrile temperature, edema and ascites; skin effects for the most part absent.
Recognizing the early stage of the disease before the development of clinical symptoms to some extent possible on the basis of determining excreted in the urine methylated amide of nicotinic acid (Nl-methyl-nicotinamide). In the norm there are 5 to 10 mg per day, in case of illness excretion falls. When recognizing which developed the disease should be borne in mind that the skin lesions are not permanent and mandatory feature of pellagra. Approximately 25% they may be missing. It is important recognition of the so-called erased forms of pellagra: only one glossitis or glossitis with stomatitis, hard ahilya with enterocolitis and trophic disorders of the nails and terminal phalanges or only one Pellegrini psychosis. To differentsirovat pellagra need from malnutrition, disease, vitamin B1 and vitamin B2.
The prediction depends entirely on when treatment is started. Fresh, timely hospitalized and properly treated cases give a favorable prognosis. Prediction in chronic pellagra questionable. It depends:
1) from the extent of involvement of the individual systems of the body and primarily the Central nervous system;
2) the age of the patient;
3) from food mode. Prediction of acute pellagra and Pellegrini psychosis is a serious.
Prevention of pellagra in areas where there was her flash is constant. The main event is the introduction of food products that contain a sufficient amount of vitamin PP (nicotinic acid). The daily requirement of an adult in nicotinic acid equal to 15 mg, pregnant women, 20 mg, lactating women - 25 mg Daily needs of the children, depending on age, 5 to 10 mg per day. Vitamin PP (nicotinic acid) and heat-resistant. Nicotinic acid rich: lean meat, Beef, lamb and pork (4 - 6 mg%), beef liver (15 mg,%), fish (fresh cod (2 mg%), fresh herring (3.5 mg%). Very rich in nicotinic acid baking and brewing yeast (40 mg%). Other plant products rich with vitamin e nuts, peanuts (8.6 mg%), mushrooms (6 mg%), buckwheat (4 mg%). Legumes: soybeans (WMG%), lentils (WMG%), beans (2 mg%). Vegetables, herbs and fruits rather poor nicotinic acid. Contain the greatest amount of vitamin PP: potatoes (1 mg%); turnip (0,80 mg%), tomatoes (0,60 mg%), peaches (0,60 mg%), spinach, carrots and beets (0.50 mg%) and other in Addition, the inclusion in the diet of foods rich in tryptophan: dairy products - milk, cheese, cheese.