Abstract

Nutritional deficiency dermatitis is rare in developed countries, seen in the context of pre-existing medical/psychiatric conditions, poverty, and nutritional ignorance. Its features are nonspecific and a comprehensive assessment is necessary for accurate and timely diagnosis. A 57-year-old male with history of epilepsy, HTN, left hemiparesis secondary to ischemic cerebrovascular accident, and ESRD on hemodialysis complicated by anemia and renal dystrophy was admitted for left foot osteomyelitis, placed on cefepime, and subsequently transferred to our institution after developing a rash concerning for Stevens-Johnson syndrome/toxic epidermal necrolysis. The patient had a diffuse, superficial desquamative rash characterized by thin brown flaky scales involving upper/lower extremities, face, and chest. Labs were notable for macrocytic anemia, elevated ALT (77 U/L)/AST (370 U/L), low zinc (54 mcg/dL)/albumin (3.0 g/dL), and metabolic derangements consistent with renal failure. Homocysteine, methylmalonic acid, folate, thiamine, Vitamin B5, Vitamin B6, Vitamin B12, and niacin were elevated or within normal limits. Differential included staph scalded skin syndrome, drug eruption, and nutritional deficiency. Shave biopsy demonstrated psoriasiform acanthosis, confluent parakeratosis, necrotic keratinocytes, and loss of the granular layer. These findings are compatible with nutritional deficiency dermatitis, necrolytic migratory erythema, acrodermatitis enteropathica, and glucagonoma syndrome. Here, the findings were attributed to malnutrition and the patient received comprehensive nutritional care prior to discharge to an acute rehabilitation unit. Here we relate a clinically challenging case of nutritional deficiency dermatitis. This entity is an important differential consideration in pediatrics, geriatrics, and patients with underlying medical/psychiatric conditions and of great clinical importance since intervention is readily accessible.