In Goldberger’s cases the eruption did not appear until after five months on the experimental diet. In the study of cases of pellagra occurring among Armenian refugees, and in Turkish prisoners of war, oedema was not infrequently noted and its occurrence usually preceded the eruption.
First Stage.—In the first stage we note the alimentary tract disturbances of sodden fissured conditions at the angles of the mouth, a large indented tongue with central coating and bare glistening sides and tips, often with a shiny mucus coating these red borders and a red buccal mucosa. The fungiform papillae appear as pinhead red elevations. Later on the tongue becomes bare, red and fissured. There is often an increased flow of saliva. Aphthous ulcers are less common than in sprue. The gums are often quite tender and in cases where they are somewhat spongy and swollen, with a tendency to bleed, we note the appropriateness of “Alpine scurvy” as a synonym for pellagra.
In cases with very severe stomatitis there may be enlargement of the salivary glands. The pharynx is congested and a similar condition of the oesophagus gives rise to a burning sensation which is often described by the patient as going up the gullet from the stomach.
Gastric disturbances, especially gastralgia, pyrosis and eructations, may be pronounced. Anacidity and deficiency of pepsin are noted in gastric juice examinations. The intestinal symptoms are those of recurring diarrhoea or occasionally of a mild dysentery but in many cases there is a normal functioning of the bowels. Although the skin manifestations usually follow those of the alimentary tract they may precede them or occur simultaneously.
The Eruption.—It is usual to designate the skin lesions of the first stage as erythematous, in that they resemble a sunburn. These pellagrous eruptions may follow some source of skin irritation as well as that from exposure to the sun; thus the perianal, perineal, vulvar, and even scrotal regions may show a marked erythema from the slight irritation of the rubbing of clothes or opposite parts. Chemical irritants may also be operative.
The pellagrous erythema shows itself most commonly during the late spring or early summer. It may appear in the early spring or late summer or early fall, but only exceptionally does it occur in the winter. There are, however, alterations in the skin previously involved which can at times be noted during the winter.
The typical eruption, however, is that which shows itself on the backs of the hands or running up beyond the wrist to the lower third of the forearm. The phalanges and especially the knuckles may also show the eruption. On the face the eruption is most common over the bridge of the nose, on the cheeks and forehead. There may be spots back of the ears or on the nape of the neck. Occasionally the butterfly outline of lupus erythematosus is seen. The face may show the so-called pellagrous mask. On the neck we may have a band-like eruption extending to the upper part of the sternum (Casal’s necklace) or the erythema may extend down the sternum (cravat).
Fig. 85.—Dry dermatitis on face, hand, neck and upper chest. Egyptian case. (From Lavinder and Babcock.)