Sandbox/01: Difference between revisions

Revision as of 12:36, 3 June 2016

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Overview

Template:DiseaseDisorder infobox Template:Search infobox Pellagra is a vitamin deficiency disease caused by dietary lack of niacin (vitamin B3) and protein, especially proteins containing the essential amino acid tryptophan.^[1] Because tryptophan can be converted into niacin, foods with tryptophan but without niacin, such as milk, prevent pellagra. However, if dietary tryptophan is diverted into protein production, niacin deficiency may still result.

Tryptophan is an essential amino acid found in meat, poultry, fish, and eggs. If your diet contains these foods, your need for niacin from other sources will be reduced.^[2]

The relationship between lysine and pellagra is unclear.^[3]

Causes

Drug Causes

Isoniazid

Symptoms

The symptoms of pellagra include:

The main results of pellagra can easily be remembered as "the four D's": diarrhea, dermatitis, dementia, and death.^[4]

Diagnosis

Physical Examination

Skin

Epidemiology

Pellagra can be common in people who obtain most of their food energy from maize, since untreated corn is a poor source of niacin (vitamin B3). Corn is also a poor source of tryptophan. This disease can be common among people who live in rural South America where corn is a staple. The symptoms usually appear during spring, increase in the summer due to greater sun exposure, and return the following spring. It is also one of several diseases of malnutrition common in Africa, and was endemic in the poorer states of the U.S. south like Mississippi and Alabama as well as among the inmates of jails and orphanages, where it was studied by Joseph Goldberger who conducted experiments in the penal colony in Rankin. Alkali treatment of the corn corrects the niacin deficiency, and was a common practice in native American cultures that grew corn. The amino acid deficiency must be balanced by consumption of other sources of protein. It was also common amongst prisoners of Soviet labor camps, the infamous Gulag. Also found in cases of chronic alcoholism.

Prognosis

Untreated, the disease can kill within four or five years.

Pellagra can be treated by treatment with niacin (usually as niacinamide). The frequency and amount of niacinamide administered depends on the degree to which the condition has progressed.

History

The traditional food preparation method of corn, nixtamalization, by native New World cultivators, who had domesticated corn, required treatment of the grain with lime, an alkali. It has now been shown that the lime treatment makes niacin nutritionally available and reduces the chance of developing pellagra. When corn cultivation was adopted worldwide, this preparation method was not accepted because the benefit was not understood. The original cultivators, often heavily dependent on corn, did not suffer from pellagra. Pellagra became common only when corn became a staple that was eaten without the traditional treatment.

Pellagra was first described in Spain in 1735 by Gaspar Casal, who published a first clinical description in his posthumous "Natural and Medical History of the Asturian Pricipality" (1762). This led to the disease being knownn as "Asturian leprosy", and it is recognised as the first modern pathological description of a syndrome(1). It was an endemic disease in northern Italy, where it was named "pelle agra" (pelle = skin; agra = rough) by Francesco Frapoli of Milan.^[6] Because pellagra outbreaks occurred in regions where maize was a dominant food crop, the belief for centuries was that the maize either carried a toxic substance or was a carrier of disease. It was not until later that the lack of pellagra outbreaks in Mesoamerica, where maize is a major food crop (and is processed), that the idea was considered that the causes of pellagra may be due to factors other than toxins.

In the early 1900s, pellagra reached epidemic proportions in the American South. There were 1,306 reported pellagra deaths in South Carolina during the first ten months of 1915; 100,000 Southerners were affected in 1916. At this time, the scientific community held that pellagra was probably caused by a germ or some unknown toxin in corn.^[7] The Spartanburg Pellagra Hospital in Spartanburg, South Carolina, was the nation's first facility dedicated to discovering the cause of pellagra. It was established in 1914 with a special congressional appropriation to the U.S. Public Health Service (PHS) and set up primarily for research. In 1915 Joseph Goldberger, assigned to study pellagra by the Surgeon General of the United States, showed that pellagra was linked to diet by inducing the disease in prisoners, using the Spartanburg Pellagra Hospital as his clinic. By 1926, Goldberger established that a balanced diet or a small amount of baker's yeast prevented pellagra. Skepticism still persisted in the medical community until 1937 when Conrad Elvehjem showed that the vitamin niacin cured pellagra (manifested as black tongue) in dogs. Later studies by Tom Spies, Marion Blankenhorn and Clark Cooper established that niacin also cured pellagra in humans, for which Time Magazine dubbed them its 1938 Men of the Year in comprehensive science.

References

↑ Pitche P (2005). "Pellagra". Sante. 15 (3): 205–8. PMID 16207585.
↑ Haas EM. "Vitamin B3—Niacin". Excepted from: Staying Healthy with Nutrition: The Complete Guide to Diet and Nutritional Medicine. Retrieved 2007-06-18.
↑ Bapurao S, Krishnaswamy K (1978). "Vitamin B6 nutritional status of pellagrins and their leucine tolerance". Am J Clin Nutr. 31 (5): 819–24. PMID 206127.
↑ Hegyi J, Schwartz R, Hegyi V (2004). "Pellagra: dermatitis, dementia, and diarrhea". Int J Dermatol. 43 (1): 1–5. PMID 14693013.
↑ ^5.00 ^5.01 ^5.02 ^5.03 ^5.04 ^5.05 ^5.06 ^5.07 ^5.08 ^5.09 ^5.10 ^5.11 ^5.12 ^5.13 ^5.14 ^5.15 ^5.16 ^5.17 ^5.18 ^5.19 ^5.20 ^5.21 ^5.22 ^5.23 ^5.24 ^5.25 ^5.26 ^5.27 ^5.28 ^5.29 ^5.30 ^5.31 ^5.32 ^5.33 ^5.34 ^5.35 ^5.36 ^5.37 ^5.38 ^5.39 ^5.40 ^5.41 ^5.42 ^5.43 ^5.44 ^5.45 ^5.46 ^5.47 ^5.48 ^5.49 ^5.50 ^5.51 ^5.52 ^5.53 ^5.54 ^5.55 ^5.56 ^5.57 ^5.58 ^5.59 ^5.60 ^5.61 "Dermatology Atlas".
↑ "Definition of Pellagra". MedicineNet.com. Retrieved 2007-06-18.
↑ Bollet A (1992). "Politics and pellagra: the epidemic of pellagra in the U.S. in the early twentieth century". Yale J Biol Med. 65 (3): 211–21. PMID 1285449.

External links

Template:Nutritional pathology

da:Pellagra de:Pellagra fur:Mâl de spelaie it:Pellagra he:פלגרה hu:Pellagra nl:Niacinedeficiëntie simple:Pellagra sv:Pellagra vec:Pelagra

Template:WH Template:WikiDoc Sources

[Pitche_2005-1] Pitche P (2005). "Pellagra". Sante. 15 (3): 205–8. PMID 16207585.

[2] Haas EM. "Vitamin B3—Niacin". Excepted from: Staying Healthy with Nutrition: The Complete Guide to Diet and Nutritional Medicine. Retrieved 2007-06-18.

[Bapurao_1978-3] Bapurao S, Krishnaswamy K (1978). "Vitamin B6 nutritional status of pellagrins and their leucine tolerance". Am J Clin Nutr. 31 (5): 819–24. PMID 206127.

[Hegyi_2004-4] Hegyi J, Schwartz R, Hegyi V (2004). "Pellagra: dermatitis, dementia, and diarrhea". Int J Dermatol. 43 (1): 1–5. PMID 14693013.

[Dermatology_Atlas-5] 5.00 ^5.01 ^5.02 ^5.03 ^5.04 ^5.05 ^5.06 ^5.07 ^5.08 ^5.09 ^5.10 ^5.11 ^5.12 ^5.13 ^5.14 ^5.15 ^5.16 ^5.17 ^5.18 ^5.19 ^5.20 ^5.21 ^5.22 ^5.23 ^5.24 ^5.25 ^5.26 ^5.27 ^5.28 ^5.29 ^5.30 ^5.31 ^5.32 ^5.33 ^5.34 ^5.35 ^5.36 ^5.37 ^5.38 ^5.39 ^5.40 ^5.41 ^5.42 ^5.43 ^5.44 ^5.45 ^5.46 ^5.47 ^5.48 ^5.49 ^5.50 ^5.51 ^5.52 ^5.53 ^5.54 ^5.55 ^5.56 ^5.57 ^5.58 ^5.59 ^5.60 ^5.61 "Dermatology Atlas".

[6] "Definition of Pellagra". MedicineNet.com. Retrieved 2007-06-18.

[Bollet_1992-7] Bollet A (1992). "Politics and pellagra: the epidemic of pellagra in the U.S. in the early twentieth century". Yale J Biol Med. 65 (3): 211–21. PMID 1285449.

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Sandbox/01: Difference between revisions

Revision as of 12:36, 3 June 2016

Contents

Overview

Causes

Drug Causes

Symptoms

Diagnosis

Physical Examination

Skin

Neck

Face

Trunk

Extremity

Epidemiology

Prognosis

History

References

Other reading

External links

Navigation menu

@@ Line 1: / Line 1: @@
-{{Infobox_Disease |
+{{CMG}}; {{AE}} {{KS}}
-  Name           = {{PAGENAME}} |
-  Image          = Paget's Disease-x-ray.jpeg |
-  Caption        = X-ray of Paget's disease |
-  DiseasesDB     = 9479 |
-  ICD10          = {{ICD10|M|88||m|86}} |
-  ICD9           = {{ICD9|731.0}} |
-  ICDO           = |
-  OMIM           = 602080 |
-  MedlinePlus    = 000414 |
-  MeshID         = D010001 |
-}}
-{{SI}}
-{{CMG}}
-'''Associate Editor-In-Chief:''' {{CZ}}
 ==Overview==
+{{DiseaseDisorder infobox |
+  Name           = Pellagra |
+  Image          = Pellagra NIH.jpg |
+  Caption        = Pellagra sufferer with [[skin lesion]]s|
+  ICD10          = {{ICD10|E|52||e|50}} |
+  ICD9           = {{ICD9|265.2}} |
+  ICDO           = |
+  OMIM           = |
+  DiseasesDB     = 9730 |
+  MedlinePlus    = 000342 |
+  eMedicineSubj  = ped |
+  eMedicineTopic = 1755 |
+  MeshName       = Pellagra |
+  MeshNumber     = C18.654.521.500.133.699.529 |
+}}
+{{Search infobox}}
+'''Pellagra''' is a [[vitamin]] [[deficiency disease]] caused by dietary lack of [[niacin]] (vitamin B3) and [[protein]], especially proteins containing the [[essential amino acid]] [[tryptophan]].<ref name=Pitche_2005>{{cite journal |author=Pitche P |title=Pellagra |journal=Sante |volume=15 |issue=3 |pages=205-8 |year=2005 |pmid = 16207585}}</ref> Because tryptophan can be [[Niacin#Biosynthesis|converted into niacin]], foods with tryptophan but without niacin, such as [[milk]], prevent pellagra. However, if dietary tryptophan is diverted into protein production, niacin deficiency may still result.
-'''Paget's disease''', otherwise known as '''osteitis deformans''', is a chronic disorder that typically results in enlarged and deformed bones. It is named after Sir [[James Paget]], the British surgeon who first described this disease<ref name="Paget">Paget J., ''On a form of chronic inflammation of bones (osteitis deformans)'', Trans Med-Chir Soc,  1877,60,37:63</ref>. The excessive breakdown and formation of bone tissue that occurs with Paget's disease can cause bone to weaken, resulting in bone pain, [[arthritis]], deformities, and fractures. Paget's disease may be caused by a [[slow virus]] infection (i.e., paramyxoviruses such as [[measles]] and [[respiratory syncytial virus]]), present for many years before symptoms appear. There is also a hereditary factor since the disease may appear in more than one family member.
+Tryptophan is an [[essential amino acid]] found in meat, poultry, fish, and eggs. If your diet contains these foods, your need for niacin from other sources will be reduced.<ref>{{cite web | author = Haas EM | title = Vitamin B3&mdash;Niacin | work = Excepted from: Staying Healthy with Nutrition: The Complete Guide to Diet and Nutritional Medicine| url = http://www.healthy.net/scr/article.asp?ID=2125 | accessdate = 2007-06-18}}</ref>
-Paget's disease is rarely diagnosed in people less than 40 years of age. Men are more commonly affected than women. Prevalence of Paget's disease ranges from 1.5 to 8 percent depending on age and country of residence. Prevalence of familial Paget's disease (where more than one family member has the disease) ranges from 10 to 40 percent in different parts of the world. Because early [[diagnosis]] and treatment is important, after age 40, siblings and children of someone with Paget's disease may wish to have an [[alkaline phosphatase]] blood test every 2 or 3 years. If the alkaline phosphatase level is above normal, other tests such as a bone-specific alkaline phosphatase test, [[bone scan]], or [[x-ray]] can be performed.
+The relationship between [[lysine]] and pellagra is unclear.<ref name=Bapurao_1978>{{cite journal |author=Bapurao S, Krishnaswamy K |title=Vitamin B6 nutritional status of pellagrins and their leucine tolerance |journal=Am J Clin Nutr |volume=31 |issue=5 |pages=819-24 |year=1978 |pmid = 206127}}</ref>
-== Risk Factors ==
+===Causes===
-*Not known
-== Epidemiology and Demographics ==
+===Drug Causes===
-The incidence of
-* Likelihood of occurrence increases with age
-* Radiologic surveys show the frequency in adults is less than 1% in the US, Great Britain, and Australia
-* The disease is rare in India, Japan, Scandanavia, and the Middle East
-== Pathophysiology & Etiology==
+* [[Isoniazid]]
-* The cause of Paget's Disease is unknown
-* The early phase of the disease is termed the destructive phase of disease
-* The next phase, commonly termed the mixed phase, involves the formation of new pagetic bone.
-In the next phase, called the ''scelrotic'' phase, the resorptive rate declines relative to the rate of bone formation leading to the development of less vascular bone and a positive calcium balance.
 ==Symptoms==
-Many patients do not know they have Paget's disease because they have a mild case with no symptoms. Sometimes, symptoms may be confused with those of arthritis or other disorders. In other cases, the diagnosis is made only after complications have developed. Symptoms can include:
+The symptoms of pellagra include:
+* High [[Photodermatitis|sensitivity to sunlight]]
+* [[Aggression]]
+* [[Dermatitis]]
+* Smooth, beefy red [[glossitis]]
+* Red [[skin lesion]]s
+* [[Insomnia]]
+* [[Weakness]]
+* [[Mental confusion]]
+* [[Diarrhea]]
+* Eventually [[dementia]]
-*[[Bone pain]] is the most common symptom. Bone pain can occur in any bone affected by Paget's disease. It often localizes to areas adjacent to the joints.
+The main results of pellagra can easily be remembered as "the four D's": diarrhea, dermatitis, dementia, and death.<ref name=Hegyi_2004>{{cite journal |author=Hegyi J, Schwartz R, Hegyi V |title=Pellagra: dermatitis, dementia, and diarrhea |journal=Int J Dermatol |volume=43 |issue=1 |pages=1-5 |year=2004 |pmid = 14693013}}</ref>
-*[[Headache]]s and [[hearing loss]] may occur when Paget's disease affects the skull.
-*Pressure on [[nerve]]s may occur when Paget's disease affects the skull or spine.
-*[[Somnolence]] (drowsiness) due to vascular [[steal syndrome]] of the skull.
-*[[Paralysis]] due to vascular [[steal syndrome]] of the vertebrae.
-*Increased head size, bowing of limb, or [[scoliosis|curvature of spine]] may occur in advanced cases.
-*[[Hip (anatomy)|Hip]] pain may occur when Paget's disease affects the [[pelvis]] or [[femur|thighbone]].
-*Damage to joint [[cartilage]] may lead to [[arthritis]].
-*Teeth may spread intraorally.
-*[[Chalkstick fracture]]s.
 ==Diagnosis==
-Paget's disease may be diagnosed using one or more of the following tests:
+===Physical Examination===
-*Pagetic bone has a characteristic appearance on [[x-ray]]s. A [[skeletal survey]] is therefore indicated.
+====Skin====
-*An elevated level of [[alkaline phosphatase]] in the blood in combination with normal [[calcium]], [[phosphate]], and aminotransferase levels in an elderly patient are suggestive of Paget's disease.
+=====Neck=====
-*Urinary Hydroxyproline has been elevated in many patients and it is a marker used traditionally.
+<gallery>
-*[[Bone scan]]s are useful in determining the extent and activity of the condition. If a bone scan suggests Paget's disease, the affected bone(s) should be x-rayed to confirm the diagnosis.
+Image:Pellagra02.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra03.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra12.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra13.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra36.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra47.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra48.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra25.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra33.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+</gallery>
+=====Face=====
+<gallery>
+Image:Pellagra19.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra32.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra39.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+</gallery>
+=====Trunk=====
+<gallery>
+Image:Pellagra23.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra24.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra43.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra45.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra46.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+</gallery>
+=====Extremity=====
+<gallery>
+Image:Pellagra04.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra05.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra06.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra07.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra08.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra09.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra10.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra11.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra14.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra15.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-== Laboratory Findings ==
-=== Electrolyte and Biomarker Studies ===
+Image:Pellagra16.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-There is an elevation of the [[alkaline phosphatase]]
-== Differential Diagnosis ==
-Since many patients are asymptomatic, the disorder is commonly discovered by radiologic examination for an unrelated disease or because of an elevated plasma [[alkaline phosphatase]].
-==Prognosis==
-The outlook is generally good, particularly if treatment is given before major changes in the affected bones have occurred. Any bone or bones can be affected, but Paget's disease occurs most frequently in the spine, skull, pelvis, thighs, and lower legs. In general, symptoms progress slowly, and the disease does not spread to normal bones. Treatment can control Paget's disease and lessen symptoms but is not a cure. Osteogenic sarcoma, a form of bone [[cancer]], is an extremely rare complication that occurs in less than one percent of all patients.
-==Other medical conditions==
+Image:Pellagra17.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-Paget's disease may lead to other medical conditions, including:
-*[[Arthritis]]: Long bones in the leg may bow, distorting alignment and increasing pressure on nearby joints. In addition, Pagetic bone may enlarge, causing joint surfaces to undergo excessive wear and tear. In these cases, pain may be due to a combination of Paget's disease and osteoarthritis.
-*[[Deafness|Loss of hearing]] in one or both ears may occur when Paget's disease affects the skull and the bone that surrounds the inner ear. Treating the Paget's disease may slow or stop hearing loss. [[Hearing aid]]s may also help. It is believed by some that the disease was responsible for Beethoven's deafness.
-*[[Cardiovascular disease]]: In severe Paget's disease (i.e. with more than 15% skeletal involvement), the heart works harder to pump blood to affected bones. Left ventricular hypertrophy is an associated finding. High-output congestive failure may rarely occur. Similarly, calcification of the aortic valve and associated vessels may occur due to turbulent flow caused by increased cardiac output.
+Image:Pellagra18.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-*[[Kidney stone]]s are somewhat more common in patients with Paget's disease.
-*[[Nervous system]]: Pagetic bone can cause pressure on the brain, [[spinal cord]], or nerves, and reduced blood flow to the brain and spinal cord.
-*[[Sarcoma]]: Rarely, Paget's disease is associated with the development of a malignant tumor of bone. When there is a sudden onset or worsening of pain, sarcoma should be considered.
-*When Paget's disease affects the facial bones, the [[teeth]] may become loose. Disturbance in chewing may occur.
+Image:Pellagra20.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-*Rarely, when the skull is involved, the nerves to the [[eye]] may be affected, causing some [[Visual loss|loss of vision]].
+Image:Pellagra21.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra22.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra26.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra27.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra28.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra29.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra30.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra34.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra35.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra37.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra38.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra40.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra41.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra42.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra44.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra49.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra50.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra51.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra53.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra54.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra55.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra56.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra57.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra58.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra59.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra60.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
+Image:Pellagra61.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-Paget's disease is not associated with [[osteoporosis]]. Although Paget's disease and osteoporosis can occur in the same patient, they are different disorders. Despite their marked differences, several treatments for Paget's disease are also used to treat osteoporosis.
-==Treatment==
+Image:Pellagra62.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-===Types of physicians===
-The following types of medical specialists are generally knowledgeable about treating Paget's disease.
-*[[Endocrinologist]]s -- Internists who specialize in hormonal and metabolic disorders.
-*Rheumatologists -- Internists who specialize in joint and muscle disorders.
-*Specialists -- Orthopedic surgeons, [[neurologist]]s, and otolaryngologists (physicians who specialize in ear, nose, and throat disorders) may be called upon to evaluate specialized symptoms.
-===Drug therapy===
+Image:Pellagra63.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-The goal of treatment is to relieve bone pain and prevent the progression of the disease. The [[U.S. Food and Drug Administration]] has approved the following treatments for Paget's disease:
-=== Chronic Pharmacotherapies ===
-Cytotoxic drugs like plicamycin and dactinomycin are no longer used for therapy
-* Bisphosphonates are used to inhibit bone resorption
-* Etidronate has been used at 20 mg/kg body weight per day and is effective in producing clinical improvement
-** osteomalacia is a potential complication of therapy
-* Alendronate, pamidronate, risendronate, and tiludronate are the bisphosphonates most commonly used now as they are more potent than etidronate and do not result in the same mineralization defects
-** Alendronate is approx. 700-fold more potent than etidronate
-** Alendronate (oral administration) and pamidronate (intravenous administration) are approved for use in the US
-Common bisphosphonates and their use:
-* Alendronate is administered orally with water 30-60 minutes before breakfast after an overnight fast
-** Dose is 40 mg/d for 6 months
-* Pamidronate is given intravenously
-** Dose is 30 mg/d in 5% glucose in water or normal saline over 4h ion 3 successive days
-* Calcitonin will be replaced by bisphosphonates for primary treatment of severe disease, but calcitonin can still be used for patients who cannot tolerate alendronate due to gastrointestinal side effects
+Image:Pellagra64.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-* The administration of calcitonins suppresses the pagetic lesion which leads to a decrease in bone pain.
-* Calcitonin also improves neurologic symptoms and decreases elevated cardiac output
-* Some individuals do not respond to porcine or salmon calcitonins
-* Calcitonin can be administered by nasal spray at doses of 200 IU/d.
-====Bisphosphonates====
-Five [[bisphosphonate]]s are currently available. In general, the most commonly prescribed are the three most potent bisphosphonates: Actonel®, Fosamax® and Aredia®. Didronel® and Skelid® may be appropriate therapies for selected patients but are less commonly used. As a rule, bisphosphonate tablets should be taken with 6-8 oz of tap water on an empty stomach. None of these drugs should be used by people with severe kidney disease.
-*Didronel® (etidronate disodium) -- Tablet; approved regimen is 200-400 mg once daily for 6 months; the higher dose (400 mg) is more commonly used; no food, beverages, or medications for 2 hours before and after taking; course should not exceed 6 months, but repeat courses can be given after rest periods, preferably of 3-6 months duration.
+Image:Pellagra65.jpg|Pellagra. <SMALL><SMALL>''[http://www.atlasdermatologico.com.br/  With permission from Dermatology Atlas.]''<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref></SMALL></SMALL>
-*Aredia® (pamidronate disodium) -- Intravenous; approved regimen 30 mg infusion over 4 hours on 3 consecutive days; more commonly used regimen 60 mg over 2-4 hours for 2 or more consecutive or non-consecutive days.
-*Fosamax® ([[alendronate sodium]]) -- Tablet; 40 mg once daily for 6 months; patients should wait at least 30 minutes after taking before eating any food, drinking anything other than tap water, taking any medication, or lying down (patient may sit).
-*Skelid® (tiludronate disodium) -- Tablet; 400 mg (two 200 mg tablets) once daily for 3 months; may be taken any time of day, as long as there is a period of 2 hours before and after resuming food, beverages, and medications.
-*Actonel® (risedronate sodium) -- Tablet; 30 mg once daily for 2 months; patients should wait at least 30 minutes after taking before eating any food, drinking anything other than tap water, taking any medication, or lying down (patient may sit).
-====[[Calcitonin]]====
-*Miacalcin® is administered by injection; 50 to 100 units daily or 3 times per week for 6-18 months. Repeat courses can be given after brief rest periods. Miacalcin may be appropriate for certain patients but is seldom used. The nasal spray form of this drug is not approved for the treatment of Paget's disease.
-===Surgery===
+</gallery>
-Medical therapy prior to surgery helps to decrease bleeding and other complications. Patients who are having surgery should discuss pre-treatment with their physician. There are generally three major complications of Paget's disease for which surgery may be recommended.
-*Fractures -- Surgery may allow fractures to heal in better position.
+==Epidemiology==
-*Severe degenerative arthritis -- If disability is severe and medication and physical therapy are no longer helpful, joint replacement of the hips and knees may be considered.
+Pellagra can be common in people who obtain most of their [[food energy]] from [[maize]], since untreated corn is a poor source of [[niacin]] (vitamin B3). Corn is also a [[Essential amino acid#Use of essential amino acids|poor source of tryptophan]].  This disease can be common among people who live in rural South America where corn is a staple. The symptoms usually appear during spring, increase in the summer due to greater sun exposure, and return the following spring. It is also one of several diseases of malnutrition common in Africa, and was [[endemic (epidemiology)|endemic]] in the poorer states of the U.S. south like Mississippi and Alabama as well as among the inmates of jails and orphanages, where it was studied by [[Joseph Goldberger]] who conducted experiments in the penal colony in Rankin. Alkali treatment of the corn corrects the niacin deficiency, and was a common practice in native American cultures that grew corn. The amino acid deficiency must be balanced by consumption of other sources of protein. It was also common amongst prisoners of Soviet labor camps, the infamous Gulag. Also found in cases of chronic alcoholism.
-*Bone deformity -- Cutting and realignment of Pagetic bone (osteotomy) may help painful weight-bearing joints, especially the knees.
-Complications resulting from enlargement of the skull or spine may injure the nervous system. However, most neurologic symptoms, even those that are moderately severe, can be treated with medication and do not require neurosurgery.
+==Prognosis==
+Untreated, the disease can kill within four or five years.
-===Diet and Exercise===
+Pellagra can be treated by treatment with niacin (usually as niacinamide). The frequency and amount of niacinamide administered depends on the degree to which the condition has progressed.
-In general, patients with Paget's disease should receive 1000-1500 mg of [[calcium]], adequate sunlight, and at least 400 units of [[vitamin D]] daily. This is especially important in patients being treated with bisphosphonates. Patients with a history of kidney stones should discuss calcium and vitamin D intake with their physician.
-[[Exercise]] is very important in maintaining skeletal health, avoiding [[weight gain]], and maintaining joint mobility. Since undue stress on affected bones should be avoided, patients should discuss any exercise program with their physician before beginning.
+==History==
+[[Image:Joseph Goldberger 01.jpg|thumb|100px|left|Portrait of Dr. Joseph Goldberger]]
+The traditional food preparation method of corn, [[nixtamalization]], by native New World cultivators, who had domesticated corn, required treatment of the grain with [[calcium hydroxide|lime]], an [[alkali]]. It has now been shown that the lime treatment makes niacin nutritionally available and reduces the chance of developing pellagra. When corn cultivation was adopted worldwide, this preparation method was not accepted because the benefit was not understood. The original cultivators, often heavily dependent on corn, did not suffer from pellagra. Pellagra became common only when corn became a staple that was eaten without the traditional treatment.
-==Microscopical Findings of Paget disease==
+Pellagra was first described in Spain in 1735 by Gaspar Casal, who published a first clinical description in his posthumous "Natural and Medical History of the Asturian Pricipality" (1762). This led to the disease being knownn as "Asturian leprosy", and it is recognised as the first modern pathological description of a syndrome(1).  It was an endemic disease in northern Italy, where it was  named "pelle agra" (pelle = skin; agra = rough) by Francesco Frapoli of Milan.<ref>{{cite web | title = Definition of Pellagra| work = MedicineNet.com | url = http://www.medterms.com/script/main/art.asp?articlekey=4821 | accessdate = 2007-06-18}}</ref>  Because pellagra outbreaks occurred in regions where [[maize]] was a dominant food crop, the belief for centuries was that the maize either carried a toxic substance or was a carrier of disease. It was not until later that the lack of pellagra outbreaks in Mesoamerica, where maize is a major food crop (and is processed), that the idea was considered that the causes of pellagra may be due to factors other than toxins.
-{{#ev:youtube|dC2TrqcEJEA}}
+In the early 1900s, pellagra reached epidemic proportions in the American South. There were 1,306 reported pellagra deaths in South Carolina during the first ten months of 1915; 100,000 Southerners were affected in 1916. At this time, the scientific community held that pellagra was probably caused by a [[germ]] or some unknown [[toxin]] in corn.<ref name=Bollet_1992>{{cite journal |author=Bollet A |title=Politics and pellagra: the epidemic of pellagra in the U.S. in the early twentieth century |journal=Yale J Biol Med |volume=65 |issue=3 |pages=211-21 |year= 1992|pmid = 1285449}}</ref> The Spartanburg Pellagra Hospital in Spartanburg, South Carolina, was the nation's first facility dedicated to discovering the cause of pellagra. It was established in 1914 with a special congressional appropriation to the U.S. Public Health Service (PHS) and set up primarily for research.  In 1915 [[Joseph Goldberger]], assigned to study pellagra by the [[Surgeon General of the United States]], showed that pellagra was linked to diet by inducing the disease in prisoners, using the Spartanburg Pellagra Hospital as his clinic. By 1926, Goldberger established that a balanced diet or a small amount of baker's yeast prevented pellagra. Skepticism still persisted in the medical community until  1937 when [[Conrad Elvehjem]] showed that the vitamin niacin cured pellagra (manifested as [[Black hairy tongue|black tongue]]) in dogs. Later studies by Tom Spies, Marion Blankenhorn and Clark Cooper established that niacin also cured pellagra in humans, for which ''Time'' Magazine dubbed them its 1938 Men of the Year in comprehensive science.
 ==References==
+<!-- ---------------------------------------------------------------
+See http://en.wikipedia.org/wiki/Wikipedia:Footnotes for a
+discussion of different citation methods and how to generate
+footnotes using the <ref> & </ref> tags and the {{Reflist}} template
+-------------------------------------------------------------------- -->
 {{Reflist|2}}
-==See Also==
+===Other reading===
+(1) Stratigos JD, Katsambas A. Pellagra: a still existing disease. B J
-* [[Paget's disease of the breast]]
+Dermatol 1977; 96: 99-106.
-* [[Paget-Schroetter disease]]
+<div class="references-small" style="-moz-column-count:2; column-count:2;">
-* [[Extramammary Paget's disease]] (EMPD)
+* {{cite journal | author = Hampl JS, Hampl WS. | title = Pellagra and the origin of a myth: evidence from European literature and folklore. | journal = J Roy Soc Med. | year = 1997 | volume = 90 | issue = | pages = 636&ndash;639 | url= http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1296679}}
+* {{cite journal | author = | title =  Reports and Resolutions of the General Assembly of the State of South Carolina, Regular Session Commencing January 11, 1916. | journal = Annual Report of the State Board of Health (1915-1916). | year = 1916 | location = Columbia, S.C. | volume = 4 | publisher = Gonzales and Bryan, state printers | url = }}
+* {{cite book |author=Beardsley E | title=The Spartanburg Pellagra Hospital. In: The South Carolina Encyclopedia |publisher=University of South Carolina Press |location=Columbia, S.C |year=2006 |pages= |isbn=1-57003-598-9}}
+</div>
-{{Diseases of the musculoskeletal system and connective tissue}}
+==External links==
+* {{DermNet|systemic/pellagra}}
+* [http://www.cyberparent.com/alternativehealth/pellagra.htm cyberparent.com]
+* [http://www.wholegrain.umn.edu/grains/corn.cfm wholegrain.umn.edu]
-[[Category:Skeletal disorders]]
+{{Nutritional pathology}}
-[[Category:Orthopedics]]
-[[Category:Needs patient information]]
-[[de:Osteodystrophia deformans]]
+[[Category:Malnutrition]]
-[[es:Osteítis deformante]]
+[[Category:Gastroenterology]]
-[[fr:Maladie de Paget]]
-[[nl:Ziekte van Paget]]
-[[pl:Choroba Pageta]]
-[[pt:Doença de Paget]]
-[[fi:Pagetin tauti]]
+[[da:Pellagra]]
+[[de:Pellagra]]
+[[es:Pelagra]]
+[[fr:Pellagre]]
+[[fur:Mâl de spelaie]]
+[[it:Pellagra]]
+[[he:פלגרה]]
+[[hu:Pellagra]]
+[[nl:Niacinedeficiëntie]]
+[[ja:ペラグラ]]
+[[pl:Rumień lombardzki]]
+[[pt:Pelagra]]
+[[ro:Pelagră]]
+[[ru:Пеллагра]]
+[[simple:Pellagra]]
+[[sv:Pellagra]]
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