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Pellagra Encephalopathy Among Tuberculous Patients: Its Relation to Isoniazid Therapy

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Pellagra Encephalopathy Among Tuberculous Patients: Its Relation to Isoniazid Therapy J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.48.7.628 on 1 July 1985. Downloaded from Journal of Neurology, Neurosurgery, and Psychiatry 1985;48:628-634 Pellagra encephalopathy among tuberculous patients: its relation to isoniazid therapy NOBUYOSHI ISHII, YASUO NISHIHARA From the Department of Pathology, University of Occupational and Environmental Health, Kitakyushushi, and the Department of Medicine, Kurate Kyoritsu Hospital, Miyatacho, Fukuokaken, Japan SUMMARY Eight cases of pellagra, diagnosed on the grounds of neuropathological findings and retrospective study of clinical data, were found among 106 necropsy cases of tuberculosis. Although these eight patients had shown various mental, neurological and gastrointestinal symp- toms, as well as skin lesions, the diagnosis of pellagra had not been made clinically. In all the patients, pellagra symptoms appeared during isoniazid therapy. Death occurred 4 to 16 weeks later. Isoniazid inhibits the conversion of tryptophan to niacin and may induce pellagra, particu- larly in poorly nourished patients. Pellagra should be suspected whenever tuberculous patients under treatment with isoniazid develop mental, neurological or gastrointestinal symptoms, even in the absence of typical pellagra dermatitis. Protected by copyright. Pellagra is a disease caused primarily by niacin sented with various mental, neurological, gastro- (nicotinic acid) deficiency and characterised by the intestinal and skin lesions during the course of classical triad of dermatitis, diarrhoea and dementia. isoniazid therapy. Clinically, pellagra had not been A niacin deficiency state can be brought about by suspected in any of them. The aim of this paper is to various causes, such as inadequate food intake, show the clinical and pathological findings of the malabsorption syndrome, increased requirement or eight cases and to call attention to pellagra administration of drugs which interfere with niacin encephalopathy without skin lesions (pellagra sine synthesis. Tuberculous patients may develop pel- pelle agra). lagra, owing to an increase in niacin requirement and isonicotinic acid hydrazide (isoniazid) therapy. Cases and methods Isoniazid is a widely used, highly effective anti- tuberculous drug. It has a structural formula similar From 1965 to 1984, 4551 patients were admitted to to niacin. Isoniazid interferes with the conversion of Kurate Kyoritsu Hospital. Of these, 1437 died and com- plete post-mortem examination was done on 1124 cases. tryptophan to niacin, by producing a deficiency in There were 106 cases of pulmonary tuberculosis. Seventy the pyridoxine coenzymes required for the conver- cases had been treated for tuberculosis until shortly before http://jnnp.bmj.com/ sion. Therefore, isoniazid may induce various mani- death. The other 36 cases had not been treated, because festations of pellagra, particularly in poorly the tuberculous lesions were old or were identified only at nourished patients. There are several reports of post-mortem examination. All the organs including the isoniazid-induced pellagra, based on clinical brain were kept in 10% formalin for 2 weeks and blocks grounds; 1-6 however, to our knowledge, no nec- were taken from each organ. Regions examined were fron- ropsy study has been published. tal lobe (areas 4 and 8), parietal and occipital lobes, We found cases Ammon' s horn and inferior temporal region, basal ganglia, eight showing neuropathological thalamus, midbrain, pons, medulla, cerebellar cortex and features of pellagra among 106 necropsy cases of dentate nucleus. Sections were stained with haematoxylin on September 25, 2021 by guest. tuberculous patients. These eight patients had pre- and eosin. In the eight cases of pellagra, Nissl, Bodian and periodic-acid-Schiff stains were also done. Clinical data Address for reprint requests: Dr N Ishii, Department of Pathology were obtained from the charts. Representative cases are (Neuropathology), University of Occupational and Environmental Health, School of Medicine, Iseigaoka 1-1, Yahatanishiku, described below. Kitakyushushi, Fukuokaken, 807, Japan. Case 1 In October 1965, the patient, a man then aged 48 years, was found to have pulmonary tuberculosis. He had Received 24 July 1984 and in revised form 6 November 1984. been an alcoholic for about 15 years, and had had alcoholic Accepted 10 November 1984 gastritis and liver dysfunction several times, but there was 628 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.48.7.628 on 1 July 1985. Downloaded from Pellagra encephalopathy among tuberculous patients: its relation to isoniazid therapy 629 no past history of alcoholic psychosis nor any other menital disease. He abstained from drinking and started to taIke isoniazid 04 g daily, p-amino-salicylic acid (PAS) 1(0g a daily and streptomycin 1-0 g im twice weekly, at a tubeer- S , culous sanatorium as an In June 1967 he ,.tC,0 out-patient. .1% ** began to show a disturbance of gait and was admitted to *": 0, 4 & the sanatorium on 15 August. By mid-September he 4 became confined to bed with paraparesis and incontinenice .. of both urine and faeces, and showed evidence of menital *,- J '%: disturbance. He was transferred to Kurate Kyoritsu Hosl,pi_ P..; tal from the sanatorium on 26 September, 1967 withl a diagnosis of acute catatonic schizophrenia. On admissiion 4.,6: he was confused and disoriented as to time and placce. P., General physical examination was unremarkable, exceept i4 for marked emaciation. Blood pressure was 142/92 mm IHg *S. a'S and pulse rate 96 per minute. No skin lesions suggestive of pellagra were noted. Neurological examination disclossed Fig 2 Central chromatolysis in neurons ofponiine nuclei. facial myoclonus, paraparesis with marked spasticity aiind H & E x 200, case 1. bilateral ankle clonus. There was slight anaemia. Othher laboratory data were all within normal limits. Lumbbar Case 2 A man, aged 21 years, was found to have pulmo- puncture revealed normal cerebro-spinal fluid. Isoniaazid nary tuberculosis and was admitted to a local hospital. He was withdrawn from 26 September, however he continuted was treated with isoniazid 0-4 g and PAS 10 g daily. About to have insomnia, visual and auditory hallucinations. IHe a year later, he started to smile for no apparent reason and muttered to himself and moved his hands all the time, as mutter to himself. He refused to eat or take any medica- though he was seeing something in front of him. FHis tion. He was sent to a mental institution where a diagnosis delirious state persisted with fluctuation of the level of of schizophrenia was made. His condition and treatment consciousness. Generalised seizure was observed twice. IHe for the next 2 years are not known to us. In September became dysphagic and died of bronchopneumonia on 7 1960, he was discharged and remained at home for one Protected by copyright. October, 1967 aged 50 years. and a half years, taking only isoniazid. In March 1962, he Necropsy revealed bilateral aspiration pneumonia and entered Kurate Kyoritsu Hospital, because his pulmonary fibrinocaseous tuberculosis in the right upper lobe. T[he condition had worsened and the sputum was positive for brain weighed 1420 g. Grossly, no abnormality was noteed. tuberculous bacilli. Treatment was begun with isoniazid Histologically there was marked central chromatolysis of 0 4 g and PAS 10 g daily, and streptomycin 1.0 g im twice neurons occurring over wide areas. The Betz cells aind a week. For the next 4 years he was treated with several other relatively large pyramidal neurons of the cerebioral other antituberculous drugs such as sulfamethoxazole, cortex, as well as the neurons of the pontine nucllei, ethambutol, ethionamide, kanamycin and cycloserine, as perihypoglossal nuclei (nucleus of Roller), arcuate nuc-lei well as isoniazid, PAS and streptomycin in various combi- and dentate nuclei of the cerebellum showed severe centitral nations. During the 4 year period he had been indifferent chromatolytic changes (figs 1 and 2). No other histto- to his surroundings and occasionally carried on a mono- pathological changes were noted in the brain. A section logue and wore an inappropriate smile, for which chlor- of the tongue revealed slight parakeratosis, acanthosis and promazine, perphenazine and minor tranquillisers were chronic inflammatory cell infiltrates in the submucosa. prescribed. Cycloserine was administered for 1 month in 1965 and 2 months in 1967, during which time there were no changes in his mental symptoms. Since October 1967, his treatment consisted of isoniazid 0-4 g, ethionamide http://jnnp.bmj.com/ al 0 3 g and ethambutol 1-0 g per day. In early August 1968, -OW he developed sunburn-like skin lesions on hands and feet. 4 9 i By late August they became typical symmetrical pellagrous I dermatitis with Casars necklace and dyssebacia on the L:.J#111.' t i. face. He was depressed and apathetic. All the antituber- 0 "k :: i l- culous drugs were discontinued for 1 month. From 26 J " 'I 416 c V "; 0 :.-,r" W." August, multi-vitamins including niacin, B1, B2, B6, B12 %-Al,t": were prescribed. The skin lesions and mental symptoms on September 25, 2021 by guest. g: cleared by 10 September. After this episode his attending :I physician changed He started to take ,4.:. twice. again isoniazid 0 r. 0-4 g and sulfamethoxazole 1.0 g per day. In July 1970 he tw N"- developed eczema-like lesions on the face and in early August symmetrical dermatitis appeared on hands, feet, face and neck. He also had diarrhoea, anorexia, vomiting, insomnia and gait disturbance with spasticity of the legs. Fig 1 Central chromatolysis in Betz cells. Nissl x 400, This time vitamin B1, B6 and B12 were given, but niacin was case 1. not prescribed, because the physician in charge did not J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.48.7.628 on 1 July 1985. Downloaded from 630 Ishii, Nishihara suspect pellagra. He expired on 10 October, 1970. Nec- administered as a first choice, along with PAS and strep- ropsy revealed old tuberculous lesions in both upper lobes.
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