Patient information: a 40-year-old female presented to the outpatient department with a four-day history of constipation, generalised body weakness, irrelevant talk, and inability to walk. She was unable to feed orally for two days before presenting to the hospital. She also complained of a generalised rash, sloughing off, and darkening of the skin on the face, neck, forearms, and dorsum of both feet. The rash was itchy and started on the forehead and spread to the cheeks and chin. The patient is HIV positive and has been on antiretroviral therapy for five (5) years now (lamivudine, tenofovir, and efavirenz). She was also on Isoniazid prophylactic therapy (300 mg) and pyridoxine (50 mg) for three months at the time of presentation. She was treated for bacteriologically confirmed TB 5 years before she presented with the above symptoms. She had quit alcohol when she was diagnosed with TB. Her main diet was corn-based, with little protein and occasional vegetables, and she lived with her two children and her cousins and was widowed.
Clinical findings: when examined, she was weak and had vital signs within normal limits: blood pressure 110/61mmHg; temperature 36.5 C; pulse 98/min; respiratory rate 18/min. Her speech was slurred. Her tongue was smooth on the oral cavity examination. She appeared distressed and had hyperpigmented lesions with fissures on the forehead, nose, zygomatic and perizygomatic regions, around the neck (Casal's necklace), on both forearms, on the dorsal areas of both feet, as seen in Figure 1. Digital Rectal Examination revealed hard, impacted stool. The rectal mucosa was smooth, and no other masses were noted. Examination of the other systems was unremarkable.
Diagnostic assessment: laboratory tests that were done are shown in Table 1. She had microcytic, normochromic anaemia, elevated ESR and HIV-1 viral load and a low CD4 count. The rest of the parameters were within reference ranges. A clinical diagnosis of isoniazid-induced pellagra in an HIV patient with constipation was entertained based on the appearance, distribution, and time frame over which the rash developed.
Therapeutic intervention: the patient was hospitalised, and the management plan initially included intravenous vitamin B complex (2mls OD), rectal evacuation with a soap enema, and lactulose syrup. Isoniazid was temporarily withdrawn and reintroduced later after dietary counselling and niacin supplements. Vitamin B3 was introduced on the second day of admission. After dermatological consultation, the entertained diagnosis of pellagra was maintained, and niacin capsules for eight weeks were prescribed. Due to the high cost of niacin, vitamin B complex tablets were instead used by the patient, and Pyridoxine dose was adjusted upwards to 50 mg twice a day for 12 weeks.
Follow-up and outcomes: the patient opened their bowels, on her own, after 48 hours of treatment with lactulose. After two weeks, the patient was reviewed, there was marked improvement of the rash, as shown in Figure 2. Her bowel habits had returned to normal after discharge from the hospital. The patient continued a high protein diet of High energy protein supplement (HEPS) and animal protein, and the generalised body weakness had resolved after a week of treatment. She was scheduled to return for review after a month but did not return.
Patient perspective: during the time she was hospitalized and after the treatment, the patient was delighted with the care she received and was optimistic about the outcome of her condition.
Informed consent: the patient was informed about the case report, why her case was peculiar and the authors' interest in publishing her case. She willingly gave informed consent to allow the authors to use her photos for this case report.
Patient s consent: informed consent was obtained from the client for us to use the pictures.