The
n e w e ng l a n d j o u r na l
of
m e dic i n e
images in clinical medicine Lindsey R. Baden, M.D., Editor
Acquired Acrodermatitis Enteropathica A
B
A
54-year-old woman presented with a 4-month history of in- Gautam Naresh Mankaney, M.D. tractable rash that was not responsive to topical glucocorticoid and antifungal Kishore Vipperla, M.D. treatment. She had undergone bariatric surgery with Roux-en-Y gastric by- University of Pittsburgh Medical Center pass about 8 years previously. She reported that during the preceding few months, Pittsburgh, PA she had stopped taking her multivitamins and had not been eating much because [email protected] of a lack of appetite and financial difficulties. On examination, an erythematous, desquamating rash associated with excoriations and honey-colored crusting was noted. The rash was predominant over the lumbosacral region (Panel A), the perioral region (Panel B), and the inguinal region, as well as on her forearms and hands in association with palmar erythema and fissuring. Skin biopsy revealed nonspecific histologic findings of parakeratosis, impetiginized regions, and chronic inflammation with dermal edema. A workup for infectious and autoimmune conditions was not revealing. An evaluation for micronutrient deficiencies caused by malabsorptive bariatric surgery and poor nutritional intake revealed a plasma zinc level of 0.31 µg per milliliter (4.7 µmol per liter) (normal range, 0.55 to 1.50 µg per milliliter [8.4 to 23.0 µmol per liter]). Acquired acrodermatitis was diagnosed, and the patient began a regimen of zinc supplementation. Nearly complete resolution of the rash was noted at follow-up 4 weeks later. DOI: 10.1056/NEJMicm1312911 Copyright © 2014 Massachusetts Medical Society.
n engl j med 371;1
nejm.org
july 3, 2014
67
The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF PITTSBURGH - MAIN on August 11, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
n e w e ng l a n d j o u r na l
of
m e dic i n e
images in clinical medicine Lindsey R. Baden, M.D., Editor
Acquired Acrodermatitis Enteropathica A
B
A
54-year-old woman presented with a 4-month history of in- Gautam Naresh Mankaney, M.D. tractable rash that was not responsive to topical glucocorticoid and antifungal Kishore Vipperla, M.D. treatment. She had undergone bariatric surgery with Roux-en-Y gastric by- University of Pittsburgh Medical Center pass about 8 years previously. She reported that during the preceding few months, Pittsburgh, PA she had stopped taking her multivitamins and had not been eating much because [email protected] of a lack of appetite and financial difficulties. On examination, an erythematous, desquamating rash associated with excoriations and honey-colored crusting was noted. The rash was predominant over the lumbosacral region (Panel A), the perioral region (Panel B), and the inguinal region, as well as on her forearms and hands in association with palmar erythema and fissuring. Skin biopsy revealed nonspecific histologic findings of parakeratosis, impetiginized regions, and chronic inflammation with dermal edema. A workup for infectious and autoimmune conditions was not revealing. An evaluation for micronutrient deficiencies caused by malabsorptive bariatric surgery and poor nutritional intake revealed a plasma zinc level of 0.31 µg per milliliter (4.7 µmol per liter) (normal range, 0.55 to 1.50 µg per milliliter [8.4 to 23.0 µmol per liter]). Acquired acrodermatitis was diagnosed, and the patient began a regimen of zinc supplementation. Nearly complete resolution of the rash was noted at follow-up 4 weeks later. DOI: 10.1056/NEJMicm1312911 Copyright © 2014 Massachusetts Medical Society.
n engl j med 371;1
nejm.org
july 3, 2014
67
The New England Journal of Medicine Downloaded from nejm.org at UNIVERSITY OF PITTSBURGH - MAIN on August 11, 2015. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.
