Serum Electrolytes in Hospitalized Pellagra Alcoholics

Serum electrolytes in hospitalized pellagra alcoholics

DF Cunha1*, JP Monteiro1, LS Ortega1, LG Alves1 and SFC Cunha1

1Nutrition Division, Department of Internal Medicine, Medical School of Uberaba, Brazil

Background: Owing to high diarrhoea and protein malnutrition frequencies in pellagra, we hypothesised that pellagra patients would have higher electrolyte disturbances than non-pellagra alcoholics. Objective: To compare serum electrolytes of hospitalised alcoholics with or without pellagra. Design: Retrospective and descriptive case-control study. Setting: Internal Medicine wards at a University Hospital, Medical School of Uberaba, Brazil. Subjects: Medical records were reviewed to obtain relevant clinical details, main diagnosis and laboratory data, including serum electrolytes on hospital admission of pellagra patients (n 33) and a randomly chosen control group of alcoholics (n 37), matched in age, gender and socio-economic status. Anaemia was ascertained by haemoglobin < 12.5 g=dl (men) and 1.5 g=dl (women), and hypoalbuminemia by serum albumin < 3.3 g=dl. Results: Pellagra and controls showed similar age (39.4Æ 13.1 vs 45.0Æ 11.4 years) and a male predominance of gender (69.7 vs 78.4%), and similar associated diagnoses, including high blood pressure (21.2 vs 16.2%), peripheral neuropathy (12.1 vs 13.5%), and pneumonia (9.1 vs 13.5%). Despite displaying similar serum sodium (136.6Æ 6.1 vs 137.8Æ 5.7 mEq=I), magnesium (1.72Æ 0.74 vs 1.62Æ 0.34 mg=dl), phosphorus (3.79Æ 0.87 vs 3.87Æ 0.78 mEq=1) than controls,in addition to higher hypoalbuminemia (76.2 vs 33%) and anaemia (60.6 vs 35.1%) frequencies. Conclusions: Higher anaemia and hypoalbuminemia frequencies associated with lower serum potassium levels suggest increased protein malnutrition prevalence among pellagrins. Descriptors: pellagra; alcoholism; hypoalbuminaemia; hypokalaemia; hypomagnesaemia European Journal of Clinical Nutrition (2000) 54, 440±442

Introduction 1993). Alcoholism, however, is the main cause of pellagra. Alcohol abuse is associated with decreased niacin intake, Pellagra, a disease rarely seen in developed countries today malabsorption, and increased intestinal and urinary niacin (Elmore & Feinstein, 1994), is characterized by bilateral losses (Vannucchi et al, 1991). In addition, alcoholics are dermatitis in sun-exposed areas, neuropsychiatric manifesta- particularly liable to niacin status derangement caused by tions, including dementia, and gastrointestinal disturbances, multiple vitamin, protein and zinc de®ciencies (Hendricks, such as glossitis and diarrhoea (Duchen & Jacobs, 1984). 1991; Vannucchi et al, 1995). Uncommon pellagra's aetiologies include Hartnup's disease, Alcoholic patients often have electrolyte disturbances that long-term isoniazid therapy, carcinoid syndrome, and other are thought to be caused by alcohol abuse, vomiting, diarrhoea conditions associated with disturbances in tryptophan meta- and poor nutrition (Ragland, 1990; Elisaf et al, 1994). Despite bolism (Duchen & Jacobs, 1984). Sporadic pellagra cases current knowledge about electrolyte disturbances in alcohol- resulting from inadequate niacin and protein intakes or ism, no reference describing serum electrolytes in pellagra malabsorption have also been described in association with patients was found in alcohol research literature. Therefore, anorexia nervosa (Judd & Poskitt, 1991), Crohn's disease and based upon the presumed high malnutrition and diarrhoea malabsorption syndromes (Pollack et al, 1982; Zaki & frequencies among pellagra alcoholic patients, we hypo- Millard, 1995; Abu-Qurshin et al, 1997). thesized that these cases would have lower serum electrolytes Notwithstanding that it is infrequently seen in industria- than a control group composed of alcoholic patients without lized countries, pellagra is still widely prevalent in some pellagra. The aim of this study was to compare serum Asia and Africa regions (Prinsloo et al, 1968; Malfait et al, potassium, magnesium, phosphorus, calcium and sodium of hospitalized alcoholics with or without pellagra. *Correspondence: D Ferreira da Cunha, Nutrition Division, Department of Internal Medicine, Medical School of Uberaba, R GetuÂlio GuaritaÂ s=n, 38025-180, Uberaba, MG, Brazil. Material and methods Guarantor: DF Cunha. This retrospective study was conducted at a 400-bed Uni- Contributors: DF Cunha had the idea, designed the study, helped to collect and check the data, did the statistical analysis and wrote the paper with versity Hospital of the TriaÃngulo Mineiro Medical School, inputs from all contributors. LS Ortega and LG Alves were responsible for Uberaba, Brazil, after of®cial approbation by the institu- data collection and organising the database. JP Monteiro and SFC Cunha tional Ethics Committee board. All pellagra patients undertaken a literature search, helped to collect and analyse the data, and (n 33), hospitalized at Internal Medicine wards from gave support in the paper writing. All contributors were involved in the preparation of the manuscript and its subsequent revisions. January of 1995 to July of 1999, were studied. In addition Received 28 September 1999; revised 23 December 1999; accepted to long-standing alcohol abuse history, the main pellagra 11 January 2000 diagnostic criterion was overt typical bilateral dermatitis in Serum electrolytes in alcoholics D Ferreira da Cunha et al 441 sun-exposed areas, with or without the concomitance of predominance (69.7 vs 78.4%), and White : non-White diarrhoea or neurological and psychiatric disturbances. The proportion (17 : 16 vs 19 : 18), as did hospital mortality typical skin lesions consisted of areas of hyperpigmentation rates (9.1 vs 8.1%). and hyperkeratosis associated with desquamation of the Pellagra group had statistically higher length of hospital epidermis in circumscribed patches, distributed symmetri- stay than controls (10.8Æ 6.2 vs 6.8Æ 5.2 days). Medical cally over the parts of the body exposed to sunlight, procedures at admission included intravenous saline and=or especially the backs of the hands, the extensor surfaces of dextrose-water 5% infusion for all cases in both groups. the forearms and lower legs, and over the face and neck Pellagra and controls, respectively, received similar intra- (Prinsloo et al, 1968). venous quantities (mEq=day) of potassium (56.0Æ 37.8 vs A randomly chosen control group of alcoholic patients 55.5Æ 24.2) and sodium (158.8Æ 73.4 vs 166.7Æ 97.8). (n 37), matched in age, gender and socio-economic status However, contrasting with 90.9% of pellagra cases, only with the pellagra group was also analysed. All cases and 54% of controls received intravenous multivitamin supple- controls were of low socio-economic status, met the DSM- ments (P < 0.01). IV criteria (1994) for alcohol dependence diagnosis, and Clinical ®ndings of pellagra were typical dermatitis had in common a history of daily intake of a half to one (100%), diarrhoea (51.5%), and neuropsychiatric manifes- liter of a Brazilian distilled alcoholic sugar cane beverage tation (21.2%). No case in the control group had diarrhoea. (45% ethanol by weight) for at least the previous 2 y. Pellagra and control groups showed similar percentages of Patient's data, including information such as age, colour associated diagnosis, including high blood pressure (21.2 vs and main diagnosis were obtained from hospital ®les, and 16.2%), peripheral neuropathy (12.1 vs 13.5%), pneumonia organized in an electronic database. The patients were (9.1 vs 13.5%), alcoholic liver disease (6.1 vs 8.1%) and classi®ed as White and non-White, according to the regis- chronic pancreatitis (9.1 vs 8.1%). tered colour, those being considered non-White being There were no signi®cant differences among pellagra described as Blacks or Mulattos. and control groups, respectively, in relation to serum The charts of the 70 patients were inspected to obtain creatinine (0.96Æ 0.33 vs 0.88Æ 0.34 mg=dl), urea relevant clinical details and laboratory data obtained on (20.8Æ 14.4 vs 25.0Æ 13.3 mg=dl), and aspartate amino- admission and before any therapeutic intervention. Some transferase (79.0Æ 53.8 vs 70.7Æ 48.9 IU) and alanine medical procedures, such as the type of hydration and aminotransferase (40.1Æ 42.4 vs 40.5Æ 33.6 IU) serum vitamin intravenous supplementation on admission were activities, the same occurring with sodium, magnesium, also registered. Patients with overt clinical manifestation or calcium and phosphorus serum levels (Table 1). biochemical ®ndings suggestive of hepatic cirrhosis or Pellagrins showed lower serum albumin, potassium, and nephrotic syndrome, as well as those receiving diuretics, blood haemoglobin (Table 1). In addition, contrasting with ACE inhibitors, total parenteral nutrition or intravenous controls, pellagra patients showed higher hypoalbuminaemia albumin supplementation, were not included. Since elec- frequency (76.2 vs 33%), and anaemia (60.6 vs 35.1%) trolyte disturbances are common in alcohol withdrawal Hypomagnesaemia was extremely common, and registered syndrome patients, no case ful®lling the withdrawal syn- in 73.7% of controls and 83.3% of pellagra cases. Hypoka- drome criteria according to the DSM-IV were included. laemia occurred in 26 cases (37.1% of total), with higher Laboratory analysis include serum aspartate aminotrans- frequency among pellagra patients (57.1%) than among ferase and alanine aminotransferase activities determina- controls (27%); the odds ratio for developing hypokalaemia tions, and blood haemoglobin and serum creatinine, was 3.60 (95% con®dence interval, 1.13 ± 11.8) in the pella- albumin, sodium, potassium, calcium, phosphorus and gra group. Pellagrins displaying diarrhoea had lower serum magnesium measurements. All serum determinations were potassium levels (mEq=l) than alcoholic patients without made using an Automatic Chemical Analyser, model diarrhoea (3.04Æ 0.89 vs 3.74Æ 0.78, respectively). Cobas Mira Plus1 (Roche Diagnostic Systems Inc., Branchburg, NJ). The laboratory reference ranges were 135 ± 148 mEq=l for sodium, 2.0 ± 4.8 mg=dl for phos- Discussion phorus, 1.9 ± 2.5 mg=dl for magnesium, 8.5 ± 10.4 mg=dl for calcium, 3.5 ± 5.5 mEq=l for potassium, 10.0 ± 34.0 IU Besides higher anaemia and hypoalbuminaemia frequen- for aspartate aminotransferase, 9.0 ± 43.0 IU for alanine cies, this study also reports lower serum potassium levels aminotransferase, and 3.5 ± 5.0 g=dl for albumin. among pellagra patients. In addition, alcoholic pellagra Anaemia was ascertained by blood haemoglobin lower patients showed increased risk of hypokalaemia. These than 12.5 g=dl (men) or 11.5 g=dl (women). Hypoalbumi- ®ndings cannot be attributed to differences in social and naemia was de®ned by serum albumin < 3.3 g=dl, and demographic characteristics, or to associated diagnoses or hypokalaemia when serum potassium was less than 3.3 mEq=l. Hypomagnesaemia was de®ned by serum mag- Table 1 Blood haemoglobin and serum albumin and electrolytes nesium less than 1.9 mg=dl. obtained from pellagra and control groups hospitalized at internal As all variables had normal distribution, they are medicine wards of the Medical School of Uberaba, Brazil expressed as meanÆ standard deviation; differences Laboratory parameters Pellagra (n 33) Controls (n 37) among patients with or without pellagra were compared Haemoglobin (g=dl)* 11.33Æ 2.27 13.09Æ 2.28 by the non-paired t-test. Fisher's exact tests were performed Albumin (g=dl)* 2.60Æ 0.84 3.19Æ 0.55 to compare frequencies. Probabilities (P) less than 0.05 Potassium (mEq=l)* 3.17Æ 0.80 3.87Æ 0.78 were considered statistically signi®cant. Sodium (mEq=l) 136.6Æ 6.1 137.8Æ 5.7 Calcium (mg=dl) 8.64Æ 1.98 8.69Æ 1.22 Results Magnesium (mg=dl) 1.72Æ 0.74 1.62Æ 0.34 Phosphorus (mg=dl) 3.79Æ 0.87 3.87Æ 1.34 Pellagra and controls did not statistically differ, respectively, in relation to age (39.4Æ 13.1 vs 45.0Æ 11.4 y), male *P < 0.05.

European Journal of Clinical Nutrition Serum electrolytes in alcoholics D Ferreira da Cunha et al 442 renal dysfunction, as de®ned by serum urea and creatinine Acknowledgement ÐFUNEPU, the teaching and searching foundation of levels. Rather, results indicate the association of hypoka- Uberaba, supported this study. laemia with diarrhoea presence in pellagra patients. Like- wise, mean magnesium serum levels were found low in both pellagra and controls, as substantiated by high hypomagnesaemia frequency. References In the present study, decreased serum albumin levels Abu-Qurshin R, Naschitz JE, Zuckermann E, Nash E, Eldar S & Yeshurun among pellagra cases cannot be attributed to differences in D (1979): Crohn's disease associated with pellagra and increased pancreatic, liver or other manifest disease frequencies, and excretion of 5-hydroxyindolacetic acid. Am. J. Med. 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