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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

CONTEXT/BACKGROUND:More than 50% of Americans use dietary supplements, and 60-70% fail to report this use to their physicians. Intoxication from vitamin D supplements has been rarely reported but may now occur more frequently. This may be attributable to an increase in vitamin D supplement intake due to the findings that deficiency is common and has been associated with a number of disease states. OBJECTIVE:We report two cases of vitamin D intoxication with dietary supplements made in the United States caused by manufacturing and labeling errors. METHODS:Case histories were obtained, and serial laboratory data (calcium and vitamin D metabolites) were measured. Each dietary supplement was analyzed by UV spectrophotometry followed by HPLC. RESULTS:In both cases, repetitive inquiries were required to elicit the use of dietary supplements. Because of significant manufacturer errors and a labeling error, patients had been consuming more than 1000 times the recommended daily dose of vitamin D(3). Hypercalcemia is directly proportional to serum 25-hydroxyvitamin D [25(OH)D] but not 1,25-dihydroxyvitamin D levels. It took approximately 1 yr to normalize 25(OH)D levels. However, once 25(OH)D levels decreased below 400 ng/ml, both patients became normocalcemic and asymptomatic without long-term sequelae. CONCLUSIONS:Although rare, vitamin D intoxication should be considered in the differential diagnosis of hypercalcemia. Patients should be asked whether they are using dietary supplements, and serial questioning may be required because patients may not consider these supplements to be potential health risks. Errors in the manufacturing and labeling of dietary supplements made in the United States may place individuals at increased risks for side effects.

Osteomyelitis underlies the majority of diabetic foot ulcers, and it is usually not detected clinically. Leukocyte scanning with indium oxyquinoline has greater sensitivity than radiographs, bone scans, and MR imaging in diagnosing osteomyelitis in diabetic foot ulcers. All ulcers that expose bone, and perhaps moderately deep ulcers as well, should be treated for osteomyelitis because of the high prevalence of this infection (100% and 82%, respectively). Osteomyelitis should be evaluated for in shallow ulcers by radiographs, followed by leukocyte scans if the former tests are negative. Bone biopsies should be performed if possible because cultures may guide antibiotic treatment

OBJECTIVE--To compare the accuracies of MRI and leukocyte scanning in diagnosing clinically unsuspected osteomyelitis in diabetic foot ulcers. RESEARCH DESIGN AND METHODS--A prospective study of 16 diabetic foot ulcers in 12 patients, including both ambulatory and hospitalized patients, was performed at a university medical center. Pedal images were obtained by leukocyte scanning with [111In]oxyquinoline and MRI. Definitive diagnosis of osteomyelitis then was determined by bone biopsy for culture and histology. RESULTS--Biopsy-proven osteomyelitis was present in 7 (44%) of the 16 foot ulcers. The diagnosis was suspected clinically in 0%. Leukocyte scanning was 100% sensitive, whereas MRI was only 29% sensitive in diagnosing osteomyelitis in diabetic foot ulcers. Specificities were 67 and 78%, respectively. The positive and negative predictive values (70 and 100%, respectively) for the leukocyte scan also were greater than those of MRI (50 and 58%, respectively). CONCLUSIONS--Leukocyte scanning is superior to MRI in detecting clinically unsuspected osteomyelitis in diabetic foot ulcers