A 30 year old female on a routine antiretroviral clinic visit presented with diarrhea, abdominal discomfort, painful swallowing, epigastric pain and a facial rash spread on the forehead, nose, cheeks and chin. The rash on the face was pruritic (Fig. 1A) especially when the patient was exposed to sunlight. There were also rashes on both fore arms, both hands and both feet (Fig. 1B-D) respectively. The patient reported to be weak and not able to perform her usual chores. At the time of presentation of these symptoms, she was on antiretroviral therapy (lamivudine, tenofovir, and efavirenz) for several years from 2015 and trimethoprim/sulfamethoxazole prophylactic therapy. Isoniazid prophylactic therapy (IPT) (300 mg) and pyridoxine (50 mg) from 4th January 2018. The patient did not have signs/symptoms of tuberculosis and had no history of tuberculosis treatment in the past. There was no history of alcoholism or cigarette smoking. She lived with her five children. A dietary history data collected revealed that the 30 year old female relied on maize as the main staple food that was often consumed with kale (green leafy vegetables locally referred to as sukuma wiki). She rarely consumed beans and meat. The woman was a farmer and did not engage in poultry keeping.
Clinical examination revealed that the patient was distressed and had hyperpigmented rashes on the forehead, nose, zygomatic and just below zygomatic regions, upper lip, lower lip, and chin. Some parts of the rashes had acne-like appearance; when squeezed gently a white substance (sebum) came out. The facial rash had a butterfly-like appearance. There were rashes on both feet and hands with no definite margins, all hyperpigmented. There were two separate rashes with definite margins on the lateral side of the right forearm just below the elbow joint. The rash closer to the elbow joint had its margins only with hyperpigmentation. The rash below was entirely hyperpigmented. Tests done include complete blood count (Table 1) which had all parameters normal including a negative VDRL. Viral load result done earlier indicated the patient was virally suppressed. An impression of pellagra (isoniazid induced) was made with differentials as sebaceous hyperplasia, acne, auto immune disorder and Systemic Lupus Erythromatosus.
The management plan included withdrawal of isoniazid and trimethoprim/sulfamethoxazole, nutritional review (dietary counseling and niacin supplements), dermatological review, nicotinamide capsules and prednisolone tablets. A review by a dermatologist confirmed pellagra. Prednisolone was stopped after one week. Nicotinamide capsules of 90 mg three times a day for 8 weeks were recommended. Pyridoxine dose increased to 50 mg twice a day for 8 weeks. The nutritionist recommended increased dietary proteins intake, preferably animal-source protein foods. Niacin supplements- Replace with 5 mg/100 g of niacin was given two level scoops per serving twice a day for 3 weeks and Ensure with 5 mg /100 g of niacin given six level scoops per serving twice a day for 5 weeks. The patient was reviewed weekly for the first 3 weeks then twice weekly. After the second week on treatment the sebum secreting rash on the face disappeared and diarrhea stopped. There was no fatigue. On the fourth week of treatment there was marked improvement on the facial rash. The facial rash was completely gone by the sixth week of treatment. All rashes had cleared by the seventh week. Treatment was extended for a week then stopped.