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DESCRIPTION
A 60-year-old man, a retired farmer, presented with scanning speech and ataxic gait for the prior 2 months and was noted to have developed a redness followed by blistering and denudation of the skin on the dorsum of the hands and front of the neck and chest for 1 month prior to presentation (figs 1 and 2).
He had marked loss of recent memory and appeared confused and at times delirious. There was mild generalised weakness and his ankle reflexes were absent. His bicep reflexes showed marked delay in relaxation.
The diagnosis of hypothyroidism was confirmed on thyroid stimulating hormone (TSH) estimation (TSH value: 1089.39 mIU/ml) and Pellagra was concluded on observing a cutaneous healing response to niacin. The patient had primary hypothyroidism as shown by the high TSH, but further aetiology could not be ascertained.
A relationship between hypothyroidism and cerebellar involvement is well known in the literature since its first description by Soderberg in 1910. The pathophysiological basis of this association remains uncertain, although it has been demonstrated in young rats that lack of thyroid hormone inhibits development of Purkinje cell dendrites.1 Even more uncommon are descriptions of Pellagra developing in patients with hypothyroidism, mostly mentioned as case reports although a pathophysiological basis has been sought in thyroid deficiency causing a deficiency of the flavoprotein system.2,3 In our patient the other important possibility could be severe hypothyroid dementia causing nutritional deficiency leading to Pellagra.
Acknowledgments
We thank all the professionals at the People’s College of Medical Sciences, Bhopal, involved in the care of this patient.
Footnotes
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.