ペラグラ患者の消化器症状の原因について

CAUSES OF GASTRO-INTESTINAL SYMPTOMS IN PELLAGRINS

I．はじめに

　ペラグラは3D主徴（Dermatitis，Diarrhea，Demen—tia）で代表される如く，皮膚症状，消化器症状，精神神経症状を呈する疾患である。その原因はニコチン酸不足によるとされているが，その他ビタミンBグループの欠乏状態も伴つていることが多いという。今日では低栄養，後進国の疾患でトウモロコシを主食とする地域に多いとされているが，欧米先進国でも時折，慢性アルコール中毒患者に，ペラグラがみられることが知られている^2）。我々は過去約9年間に，慢性アルコール中毒患者58例の剖検を行つたが，そのうち16例にペラグラを見出した。その臨床及び病理所見は，すでに述べた通りである^8）。即ち，幻覚，錯乱，振戦譫妄，不安，不眠，痙攣，腱反射亢進などの精神神経症状は，Betz細胞，皮質の比較的大きい錐体細胞，橋核神経細胞その他のCen—tral chromatolysisにその病理学的根拠を求めることができる。又ペラグラの皮膚症状は，日光に当たる顔面，頸部，手掌，足背などにみられ，病理学的には過角化症，錯角化症，顆粒層の増大，乳頭部の慢性炎性細胞浸潤などの所見がみられる。然らば下痢，便秘，嘔吐，食思不振などの消化器症状の原因ないし病理学的な裏付けは何であろうか？　ペラグラに関する文献は1930年代より数多くあり，成書にもその臨床症状及び病理所見は詳しく記載されているが，消化器症状の原因に言及しているものはない^{2,4,9,10,12,14）}。今回我々は16剖検例について消化器症状の原因を検索したので報告し，若干の考察を加えたい。

Sixteen autopsied cases of pellagra were reported. All the patients were chronic alcoholics and were males. Clinically they presented with psychologicalsymptoms, such as hallucination, confusion, delirium tremens and insomnia. Neurologically there were muscle spasticity, hyperrefiexia, peripheral neuro-pathy, generalized seizure and ataxia. Gastro-intestinal symptoms were diarrhea, constipation, anorexia, vomiting and glossitis. Only 4 patients developed skin lesions, which were not typical of pellagra. Therefore clinical diagnosis of pellagra was not made and nicotinic acid was not given. Most of the patients took downhill course with persistentd eelirium tremens, gastro-intestinal symptoms and expired of bronchopneumonia within a few months.

Autopsy revealed central chromatolysis of Betz cells, large pyramidal cells in the frontal and parietal cortex, neurons of the pontine nuclei, arcuate nuclei, hypoglossal nuclei, nuclei of ambiguus. anterior horn of the spinal cord, dorsal motor nuclei of vagus and Auerbach's plexus of the intestine. Liver diseases, such as cirrhosis, fatty liver and fibrosis were present in 9 patients.

Particular effort was made in order to clarify the causes of gastro-intestinal symptoms in this study. Clinically diarrhea was observed in 9 patients (3 to 10 movements per day), constipation in 3 patients, anorexia in 9 patients, vomiting in 4 patients and glossitis in 11 patients. Pathological findings of the gastrointestinal tract were as follows; chronic atrophic gastritis in 7 patients, gastritis catarrhalis in 2 patients, polyp of the stomach in 2 patients, submucosal petechial hemorrhage of the stomach in 1 patient, submucosal petechial hemorrhage of the colon in 2 patients, erosion of the colon in 1 patient. None of these pathological findings were sufficient enough as the causes of gastro-intestinal symptoms in those patients.

Neurons of the dorsal vagal nuclei were examined as to the incidence of central chromatolysis and were compared with 10 control patients. In aver-age, these pellagra cases had 10.5 neurons with central chromatolysis, whereas the control group had only one neuron with chromatolysis-like changes. In 4 cases, the neurons of Auerbach's Plexus of the intestine showed central chromatolysis.

The possibility that the gastro-intestinal symp-toms, such as diarrhea, constipation, vomiting and anorexia were caused by pathological changes of the autonomic nervous system, that is central chromatolysis of the neurons, was mentioned.

Diagnosis of pellagra is difficult, without skin lesions (pellagra sine pelle agra), but one should suspect of the disease when chronic alcoholics present with neurologic and mental symptoms.