Flushing Due to Niacin Deficiency in a Patient with Crohn's Disease

Presentation Number: SUN 297
Date of Presentation: April 2nd, 2017

Lisa G Newman*1, Robert J Cohen2 and Melissa H. Rosen1
1NYU School of Medicine, 2Columbia University School of Medicine

Abstract

Background: There have been rare reports of niacin deficiency in patients with Crohn’s disease. We report a case in which a patient presented with flushing.

Clinical case: A 31-year old woman with a history of Crohn’s disease was referred by her dermatologist for flushing. Six months prior, she began experiencing erythema of the chest area every other day. The flushing was described as uncomfortable and pruritic, and she found it distressing. There were no identifiable precipitating factors, such as foods, exercise, or stress. There had been no new medications prescribed. She denied use of dietary supplements or herbal remedies. The patient was evaluated by an allergist & immunologist and it was determined that the rash was not due to an allergic reaction.

The patient’s history was notable for necrotizing enterocolitis as a newborn, requiring a partial colectomy, and an ileostomy that was reversed 2 years later. At age 10 years she was diagnosed with rectal and perianal Crohn’s disease. Due to lack of response to glucocorticoids, sulfasalazine, and infliximab, the patient underwent an ileostomy 4 months prior to the onset of flushing. Of note, the patient did not have evidence of ileal Crohn’s disease. She also has a history of polycystic ovarian syndrome. Her medications at the time of presentation were an estradiol-norelgestromin 150-35 mcg transdermal patch twice weekly and sulfasalazine 2000mg daily.

Laboratory evaluation revealed a low vitamin 25(OH)D level at 16 ng/ml. Normal blood test results were found for CBC, Sma20, TSH, FT4, lipid profile, as well as an evaluation for polycystic ovarian syndrome including PL, testosterone, DHEAS, 17OHP, ACTH, serum cortisol, and HbA1c. Normal laboratory values were found for flushing and nutritional parameters included vitamin A and B12, 24 hour urine 5HIAA/creatinine, plasma metanephrines, and histamine, serum calcitonin, chromogranin A, and tryptase.

The pattern of the rash was reminiscent of a milder form of textbook pictures of pellagra, a condition commonly referred to as the 3 D’s: dermatitis, diarrhea, and dementia. Niacin is primarily absorbed in the ileum, much of which had been surgically resected in this patient. Therefore nicotinic acid and nicotinamide levels were sent and found to be undetectable, <20 ng/ml. The patient was prescribed one flush-free niacin tablet (Nature Made, USP, 500mg inositol hexanicotinate), along with B complex and vitamin D3 2000IU daily. The flushing resolved within two weeks. A repeat serum nicotinamide level at that time had risen to 26 ng/nl. Seven months later, the patient remains symptom free.

Conclusion: Niacin deficiency should be included in the differential diagnosis of flushing, particularly in patients with a history of surgically resected ileum, or active ileal disease, which can both interfere with niacin absorption.

 

Nothing to Disclose: LGN, RJC, MHR