Case Presentation:

A 51‐year‐old female who had previous multiple hospitalization for altered mental status and persistent diarrhea was admitted with complaint of twitching sensation on right side of her face and arm. Her past medical history was significant for Sjögren's syndrome, coronary artery disease, COPD, diabetes mellitus type II, hypothyroidism, and Burgers disease with multiple amputations of fingers and a left below‐knee amputation 3 years back. At presentation, her vital signs were normal. Oral cavity exam was significant for a swollen scarlet‐red tongue without gum disease. She was not oriented to time and place though able to follow simple commands; the est of neurological assessment was unremarkable. Skin evaluation revealed marked erythema at leg stump with no other rash. Neurological workup including imaging was negative. The patient continued to be disoriented with hallucinations and confusion throughout her hospital course with complaints of extreme fatigue. Her oral cavity symptoms was earlier thought to be secondary to Sjögren's syndrome, but given her persistent delirium and diarrhea, we checked for vitamin B complex or vitamin C deficiency. Left leg erythema was considered secondary to chronic arterial insufficiency, possible cellulitis. Colonoscopy was performed for further evaluation of diarrbea that suggested scattered small superficial benign colonic ulcers & benign colon polyps; biopsy was negalive for Congo red staining. Consequently, laboratory results unveiled the diagnosis of niacin and vitamin C deficiency with serum levels < 0.5 and < 0.1 μg/mL, respectively.


Early presentation of nutritional deficiencies is often vague and can mimic more common conditions. The case demonstrates how the symptoms of vitamin deficiencies can be overlooked. The patient had symptoms of pellagra, including diarrhea and dementia, but without dermatitis, possibly because of very limited sunlight exposure. In addition, she had marked erythema at the amputation site, a sign of poor wound healing seen in advanced vitamin C deficiency, but surprisingly she did not have other signs including petechiae, perifollicular hemorrhages, corkscrew hairs, or gum hyperplasia. Although the causes of vitamin deficiencies are not very clear in this case, malnutrition due to her bed‐bound status could be a reason; further workup to for secondary causes of niacin deficiency including carcinoid syndrome and Hartnup disease is in progress.


Nutritional deficiencies are rare but still occur in United States and should be considered in differential diagnosis in population at risk including bed‐bound patients and those with alcoholism and malabsorption states. It is important to continue acknowledging the role of nutrition in preventing serious illness and recurrent hospitalization.

Author Disclosure:

K. Manzoor, none; B. Shaalan, none; W. Aftab, none; K. John, none.