**Question:** In pellagra, all are seen except -

A. Hyperpigmentation
B. Hypogonadism
C. Hypoalbuminemia
D. Skin rash

**Correct Answer:** B. Hypogonadism

**Core Concept:** Pellagra is a nutritional deficiency disease caused by a lack of niacin (vitamin B3), which is essential for the proper functioning of various enzymes involved in carbohydrate, protein and fat catabolism, and DNA synthesis.

**Why the Correct Answer is Right:** Hypogonadism refers to a deficiency or dysfunction of the sex glands (testes in males and ovaries in females), leading to reduced hormone production, particularly testosterone in males and estrogen in females. In pellagra, hypogonadism is not a prominent feature as it is a consequence of advanced disease stage and is less common than the early signs and symptoms.

**Why Each Wrong Option is Incorrect:**

A. Hyperpigmentation: This refers to an increased pigmentation of the skin, which is common in pellagra due to increased melanin production as a protective response to inflammation and oxidative stress caused by niacin deficiency.

C. Hypoalbuminemia: This is a decrease in serum albumin levels, which can be observed in pellagra due to liver dysfunction and malnutrition.

D. Skin rash: The characteristic skin rash in pellagra is known as the "four D's" sign, which includes dermatitis (skin inflammation), dementia (cognitive impairment), diarrhea (gastrointestinal symptoms), and death (advanced stage). Although skin rash is a common sign of pellagra, it is not seen in all cases, particularly in early stages.

**Clinical Pearl:** Pellagra has a triad of symptoms: dermatitis, dementia, and diarrhea, which can help identify the disease in its early stages when treatment is most effective.

**Explanation of the wrong options:**

Option A (hyperpigmentation) is incorrect because it is seen in pellagra due to increased melanin production as a protective response to inflammation and oxidative stress caused by niacin deficiency.

Option C (hypoalbuminemia) is incorrect because hypoalbuminemia is a result of liver dysfunction and malnutrition in pellagra patients.

Option D (skin rash) is not always seen in pellagra, especially in the early stages of the disease, unlike the "four D's" sign, which includes dermatitis, dementia, diarrhea, and death.