Physical Examination Techniques

Classic physical assessment involves inspection, palpation, percussion, and auscultation, generally performed in that order (174).

Vitamin/mineral imbalance in dialysis patients affects tissue integrity of the mouth, skin, scalp, eyes, hair, hair follicles, and nails. Inspection and light palpation are techniques used most frequently. While presentation of vitamin and mineral lesions can be discrete, they are generally bilateral in the absence of injury.

5.4.1. Examination of the Mouth

The lips are smooth, a deeper color than the face, with a clear vermilion border. Vertical cracking (cheilosis) or erosion at the corners (angular stomatitis) may be observed in active lesions; scarring may be present if deficits have occurred in the past. Breath odor suggests gingivitis if dank with decayed food, oral Candida if yeasty in people with diabetes or iron deficiency (175), or elevated BUN if ammoniacal (174). An understanding of the patient's dental hygiene, time since the last dental visit, and bleeding with brushing will help determine the etiology of oral lesions. Cracked, fractured teeth at the gum line become sources of infection and abscess. Ill-fitting dentures following weight loss adversely affect ability to chew and may cause maceration at the corners of the mouth. The extended tongue will reveal color and texture. Usual pigment is deep pink, with fingerlike projections (papilla) scattered evenly over the surface of the tongue. Erosion of papilla at the tip and lateral aspects of the tongue may suggest early nutrient deficiency; balding with complete atrophy and lesions suggests long-term disease (176). The bald tongue on nutrient replacement will develop new papilla in the central portion of the tongue first, with papilla returning at the tip and lateral aspects last.

5.4.2. Examination of the Scalp, Hair, and Skin

The scalp is observed at the natural separation in the hair and is intact with natural oil. The patient is asked to show areas of soreness or itching. Frequency of hair washing affects texture of hair and may correlate with itchiness. Hair should be evenly distributed without patchiness on the scalp. Absence of hair on the lower extremities may suggest vascular compromise. The hair shaft is straight, whether round or flat, emerging easily from a smooth hair follicle. A magnifier will help establish whether the shaft is coiled or the follicle is hyper-keratosed. Skin along the hairline, behind the ears, and between the eyebrows is in tact with adequate lubrication; in nutrient deficiency, these are primary sites for seborrheic-like dermatitis. Skin around the neck and shoulders, along the arms and down the lower extremities, is assessed for skinfold, muscle integrity.

Observing the scalp at the hair part, the skin at the midpoint of the upper arm, and above the lateral malleolus (ankle) will provide easy reference points for future comparison. Periorbital and sacral tissues may be sites for edema; pitting at the ankle or sock line upwards toward the knee may be graded.

5.4.3. Examination of the Eyes

The tissue adjacent to the eyes should be intact, without inflammation or swelling. The lateral palpebral commissure (corner of the eye) is generally darker in color, without redness or irritation. Eyes are adequately bathed, without excessive tearing. The lower palpebral conjunctiva is examined by placing the index finger beneath the lower eyelid and gently easing the facial tissue downward, as the patient looks up. Normal conjunctiva shows a rich pink capillary bed beneath a pale anterior rim; pallor is defined as little or no red color beneath the anterior rim (177). The iris meets the white sclera at the limbus. A raised yellow plague (pinguecula) is a normal finding that may emerge along the horizontal plane of the eye at the limbus in aging (174). However, clear glass-like crystals, observed by glancing alight off the surface of the eye at the limbus in the 3:00 and 9:00 positions of the eye, suggests calcific band keratopathy resulting from calcium/phosphorus imbalance (178).

5.4.4. Examination of the Nails

Normal nail plates are clear in color, smooth in texture, and convex in both directions. Longitudinal dyschromic bands or vertical ridging in the nail plate are normal variants. Rubbing a gloved thumb over the nail plate from side to side, nail bed to tip will reveal abnormalities in shape and texture. Spooning of the nail plates (koilonychia) suggests iron deficiency or environmental exposure to water (179). Horizontal ridging is abnormal, and of particular significance when found as Beau's Lines, singular arcuate erosions seen on all nail plates (180). Pitting may occur in psoriasis. The nail bed is pink in color, with a half mooned lunula at the proximal nail. The nail bed blanches when light pressure is applied at the nail tip, with capillary refill in less than 3 seconds. Tissue around the nail is smooth without signs of inflammation or infection.

  1. 5. Physical Findings and Functional Deficits in Niacin, V-B6, and Zinc Imbalance
  2. 5.1. Niacin

Pellagra was prevalent for many years with the understanding that it occurred with poverty and corn intake. Joseph Goldberger of the United States Public Health Service reproduced pellagrous symptoms in dogs, leading to the discovery that yeast could prevent and cure pellagra (181). Bean (176) graded the symmetrical, bilateral dermatitis

Drug/Nutrient Interactions:

Statin-type Hypolipemics (255)

5-Fluoro-uracil (194) Isoniazid (194) Pyrazinamide (194 )

6-mercaptopurine (194) Hydantoins (194) Phenobarbitol (194 ) Chloramphenicol (194 )

Deficits in iron, riboflavin, or Vitamin B6, Zinc decrease conversion of tryptophan to Niacin.

With adequate co-factors, 60 mg dietary tryptophan is converted to 1 mg Niacin

Biochemical Evaluation:

Plasma 2-Pyridone niacin derivative

Plasma N1-methyl-nicotinamide

High Niacin/Toxicity:

Elevated Liver Function Tests (LFT's) (257) Elevated Bilirubin (257)

More prevalent in time released Nicotinic Acid (258, 259).

Function/Absorption/Elimination:

Function: Co substrate, coenzyme for hydride ion transfers in dehydrogenases.

Absorbed: Stomach and intestine by Na+ facilitated diffusion at usual intakes; passive diffusion at high intakes

Elimination: Excess excreted in urine (normals); Niacinamide is metabolized in the liver

Medical Diagnoses:

Alcohol Misuse (260) Crohn's Disease (194) Malnutrition involving iron, riboflavin, B6, or zinc deficits.

Heart failure, hepatitis may precipitate Niacin toxicity if liver is not perfused adequately or incapable of clearing nutrient (Personal experience)

Dialysis

: Not established.

Niacin Deficiency Skin Findings

Food Sources: (> 8 mg/svg) Chicken breast, Cornish game hen, Highly fortified breakfast cereal, Tuna, Swordfish, Sturgeon, Trout, Veal, Liver, and Brewer's Yeast

US Diet Sources:

Mixed foods, Poultry, ready to eat Cereals, Beef, and Processed meats

RDA:

16 mg Male 14 mg Female

Upper Limit: 35 mg (flushing, mediated by histamine; moderated by aspirin 325 mg) (256)

Total Body Store: Not clearly understood; Half-life 45 minutes (255).

Physical Findings/Functional Deficits: Deficiency: Pellagra - "3 D's" Dermatitis (190): Reddened skin darkens, vesicles, bullae develop with desquamation; Bilateral symmetrical distribution on sun exposed skin (Casal Necklace); Skin thickened, pigmented over joints; Palms, soles dry, scaling with rough elbows. Diarrhea (182): Raw, burning from mouth to rectum. Dementia (194): Confusion, confabulation, memory loss, disorientation, and delirium. Oral (182):Scarlet sore tongue, filiform papillae progressing to complete atrophy. Neurological (261): Confusion, Loss of memory, Disorientation, Confabulation, Mania, Depression, Delirium, and Polyneuritis. TOXICITY (256): Vasodilation, Nonspecific gastrointestinal effects, Jaundice with hepatotoxicity.

Fig. 5. Comprehensive niacin assessment in renal failure. If not annotated otherwise, data cited from ref. (188).

of sun-exposed skin, and redness, inflammation and papillary atrophy of the tongue found in niacin deficiency. In 1952, Goldsmith et al. (182) astutely monitored niacin depletion in women eating a corn or wheat diet, supplemented with tryptophan to ensure minimal nitrogen balance (183) and adequate B-vitamins, without niacin. Lesions developed within 40-135 days in isolated niacin deficiency, with half the subjects experiencing some symptom by day 50. Oral lesions occurred with and without characteristic blistering, necrotic skin associated with pellagra (182). Goldsmith coined the term "Pellegra sine Pellagra" from the historical literature (184), documenting deficiency without skin lesions.

Pellagrins continue to elude diagnosis when they present without skin lesions. A necroscopy study diagnosed 20 cases of pellagra with

Scarlet Tongue Niacin Deficiency
  1. Scarlet, atrophied tongue "Pellegra Sine Pellagra" Niacin 3.6 ng/mL (R 3.5-7.0) ©Steve Castillo
  2. Early skin peeling "Pellegra Sine Pellagra" Niacin 3.6 ng/mL (R 3.5-7.0) ©Steve Castillo
Pellagrous Stomatitis
  1. Angular stomatitis Pellagra Niacin 1.9 ng/mL (R 3.5-7.0) ©Steve Castillo
  2. Scarlet, bald tongue Pellagra Niacin 1.9 ng/mL (R 3.5-7.0) ©Steve Castillo
  3. Angular stomatitis Pellagra Niacin 1.9 ng/mL (R 3.5-7.0) ©Steve Castillo
Pellagra Scalp
  1. 6. Nutrient-based lesions associated with laboratory validated niacin deficit. Photographs may not be reproduced, copied, projected, televised, digitized, or used in any manner without photographer's express written permission.
  2. Bullous lesions Pellagra Niacin 3.0 ng/mL (R 3.5-7.0) ©Steve Castillo
  3. Necrotic skin blebs Pellagra Niacin 3.0 ng/mL (R 3.5-7.0) ©Steve Castillo
  4. 6. Nutrient-based lesions associated with laboratory validated niacin deficit. Photographs may not be reproduced, copied, projected, televised, digitized, or used in any manner without photographer's express written permission.
Physical Signs Kidney Problems
(i)
  1. Exfoliated knuckles Pellagra Niacin 1.9 ng/mL (R3.5-7.0) ©Steve Castillo
  2. 6. (Continued)
  3. Exfoliated knuckles Pellagra Niacin 1.9 ng/mL (R3.5-7.0) ©Steve Castillo
  4. 6. (Continued)

neuropathology from 74 chronic alcoholics who presented only mental, neurological, and GI symptoms at death (185). Although pellagra is frequently related to alcohol or malabsorption (186,187), use of non-fortified grains like rice and corn as primary energy sources, combined with low protein diets, can expedite niacin deficiency. Pre-formed niacin is derived primarily from fortified breads and cereals (188). Food intake data from rice-eating PD patients (189) tallied thiamin, niacin, and riboflavin intakes between 50 and 83% of the Recommended Dietary Allowances (RDA).

Functional niacin deficits include diarrhea, with and without bleeding, dysphagia, nausea, vomiting, and anorexia (190). Autopsy reports reveal scarlet, exfoliated oral surface, extending throughout the GI tract (191). Diffuse inflammation is also found in vaginal mucosal tissues (182,192,193); amenorrhea is common (182,191). Long-term neuropsychological manifestations of photophobia, asthenia, depression, hallucinations, confusion, memory loss, and psychosis

(194) are thought to be mediated by impaired conversion of tryptophan to the neurotransmitter serotonin (193). Early unresolved cases resulted in dementia and death (191,195).

A comprehensive niacin assessment is shown in Fig. 5. Pellagrous lesions observed in dialysis patients at San Francisco General Hospital (Fig. 6) include sore, scarlet, atrophied tongue, angular stomatitis, bullous skin vesicles, necrotic blebs, and exfoliated elbows, palms, and knuckles. Pellagra sine Pellagra was also observed with severe glossitis and mild, tissue-like peeling of the skin.

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