Abstract:

A 54-year-old female with history of Roux-en-Y gastric bypass and alcohol abuse was admitted to the medical intensive care unit for gastrointestinal bleed and sepsis. She was noted to have a desquamating rash and dermatology was consulted. Physical exam revealed pink macules coalescing into large patches of blanching erythema with extensive overlying erosions on the left lower back, buttocks, right inguinal fold, and posterior thighs. The differential diagnosis included resolving drug reaction vs infection vs desquamation from immobility. A punch biopsy was performed on the right thigh. Sections revealed a relatively sparse superficial perivascular lymphocytic infiltrate. The overlying epidermis was thin with pallor and dyskeratosis of the superficial layers. There was overlying orthokeratosis. Overall, the findings of superficial epidermal pallor and dyskeratosis were highly suggestive of a nutritional deficiency. Laboratory testing revealed a zinc deficiency with a serum zinc level of 25 ug/dL. The patient received supplementation with zinc sulfate 220 mg daily via feeding tube. Unfortunately, the patient developed septic shock that did not improve with broad-spectrum IV antibiotics and maximum vasopressor support. She subsequently passed away. Zinc deficiency, also known as acquired acrodermatitis enteropathica, can manifest as erythema, erosions, and scaling, especially in the perioral, acral, intertriginous, and anogenital regions. Other findings include alopecia, paronychia, nail dystrophy, stomatitis, and diarrhea. Risk factors for zinc deficiency include low nutrition and malabsorptive states such as anorexia nervosa, alcohol abuse, total parenteral nutrition, and gastric bypass. This case highlights the importance of recognizing this diagnosis, especially in patients with risk factors.

Financial Disclosure:
No current or relevant financial relationships exist.

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Amy Zhang, MD