Pellagra is a deficiency in vitamin B3 or niacin. Though not a problem in the U.S., instances exist throughout the world. First identified as a nutritional disease in Spain in 1735 by Don Gaspar Casal, Pellagra was originally known as mal de la rosa due to its characteristic symptom: red, rough skin. In 1914, Joseph Goldberger began studying the root of the problem.

Pellagra Flourished in the Old World

As exploration of the New World flourished, maize or corn became a staple in diets throughout Europe. While corn itself does not cause pellagra, its preparation created problems. Native Americans used lye when cooking corn, similar to how hominy is made. This process, nixtamalization, helps release niacin and tryptophan from the corn, rendering it bioavailable. Thus treated, corn can be made into grits, flour, and masa, which the Native Americans used to make corn tortillas. Europeans were not aware of this process, and as their corn consumption increased, niacin deficiency became more commonplace.

The Four D’s

Pellagra is often characterized by the four D’s:

• Diarrhea, which is not always present.
• Dermatitis, which can appear as a sunburn or erythema. Skin lesions may also appear. Sunlight exacerbates the reddening of the skin, which may at first be mistaken for sunburn.
• Dementia
• Death

People with pellagra can also develop headaches, seizures, and rigidity, and not everyone will develop all four Ds. Casal’s collar refers to a common symptom of pellagra, a rash around the neck. Other early signs include vomiting, irritability, and rashes on the hands. Some experience inflamed mouths or throats.

What Causes Pellagra?

A diet deficient in vitamin B3 or niacin causes pellagra. Tryptophan helps the body utilize nicotinic acid, thus a diet low in meat, dairy, fish, and eggs, results in a shortage of this essential amino acid. A balanced diet reduces the risk of pellagra, beri-beri, scurvy, and other nutritional deficit diseases. There are two types of pellagra: primary and secondary. The primary form stems directly from a lack of vitamin B3. Secondary pellagra results from medications, alcoholism, chronic diarrhea, and sometimes allergies, which can all interfere with the body’s ability to use or absorb niacin and tryptophan. Secondary pellagra can be more difficult to cure.

Pellagra in the United States

Pellagra was once rampant in the United States, particularly in the South following the Civil War. As many people had lost their cattle and crops, they ate whatever was cheap and available. Corn became a staple in many diets. Cotton mill workers, coal miners, sharecroppers, and people in mental institutions were often diagnosed with pellagra because they often ate cornmeal and had little variety. The use of the Beall Degerminator worsened the problem, as it removes much of the niacin from corn. In the four years spanning from 1907 to 1911, there were 16,000 confirmed cases of pellagra with nearly a 40 percent death rate in just eight southern states. South Carolina alone reported almost thirty-thousand cases by 1912, with the same alarming death rate. With no identifiable cause, pellagra fluctuated based on the economic factors that influenced food supplies.

Identifying Pellagra’s Cause

As pellagra reached epidemic proportions, Dr. Joseph Goldberger, a renowned specialist in infectious disease, began to research its cause for the U.S. government. Most people at the time still believed pellagra was an infectious disease, but Dr. Goldberger had a different opinion. He went so far as to inject himself and his assistant with blood from people who had the disease to prove pellagra was not infectious.

Dr. Goldberger Tests His Theory

Dr. Goldberger began experiments on people he knew he could follow for a lengthy time. He ran tests at the Mississippi State Prison Farm where prisoners received an early release for their participation. Dr. Goldberger gave twelve men a diet consisting almost exclusively of corn. After six months, half the men had developed symptoms, which disappeared when meat was reintroduced into their diets. Goldberger also ran experiments in orphanages and asylums, with some subjects already diagnosed with pellagra. Dr. Goldberger provided balanced meals and removed corn from their diets. Despite a rise of pellagra in the general population, the test subjects’ symptoms improved, with only one recurrence out of 172 children and 72 asylum inmates.

Rise and Fall of Pellagra

Pellagra declined in Italy in the early 1900s when the government helped create cheap wheat and bakeries throughout the country — whole wheat is high in niacin. It remained a problem in the United States however, even following Dr. Goldberger’s findings. People who had already experienced a bout of the disease were the most likely to have a recurrence, especially when food supplies were scarce. The disease made a big comeback during the 1920s when the cotton market dropped.

The Government Acts to Fight Pellagra

Following Dr. Goldberger’s studies, the government began to encourage people to keep some of the milk they produced, which contains small amounts of niacin. Unfortunately, this was not helpful to the people who had pellagra as a result of poverty, or who didn’t own a cow. The government began to require the addition of niacin and other vitamins to flour and cereals in 1947. This greatly reduced cases of pellagra and is considered instrumental in eradicating the disease in the U.S.

Vampires with Pellagra

The rise in vampire folklore during the 1700s may be linked to pellagra. Their inability to withstand sunlight, their aggression and insomnia, are all similar to the symptoms that people with pellagra experience. Given the rise of pellagra in Europe at the time vampire folklore was popular, many people believe pellagra may have inspired the tales.

Preventing Pellagra

Consuming a varied diet rich in legumes, meat, eggs, and dairy largely prevents pellagra. The disease still exists in areas where meals primarily consist of corn, and in regions that rely only on sorghum. Using enriched flours, cereals, and a daily multivitamin can help meet the body’s niacin requirements when regular diet falls short.