A 42 y.o. woman who had a Roux-en-Y gastric bypass in 2004 presents with a rash on her hands.

 What is the cause of the rash?

What is the cause of the rash?

Our patient had zinc deficiency  also known as acrodermatitis enteropathica if it is a congenital defect in zinc carrier protein ZIP4 .  Zinc deficiency may have been caused  in our patient by a combination of factors since she was an alcoholic, had a Roux-en-Y gastric bypass,  and had chronic pancreatitis causing malabsorption.  Her zinc level was documented to be low on several occasions.

Zinc deficiency is most commonly caused by decreased dietary intake and 25% of the world’s population is at risk. Specifically,  zinc deficient soils are found in several areas of the world, notably in central Turkey.  Lack of zinc is responsible for increased rates of malaria, diarrhea and pneumonia since it plays a role in immune function.  Zinc deficiency may lead to anorexia nervosa.  A 1994 trial showed that zinc doubled the rate of body mass increase in the treatment of anorexia nervosa. Wilson’s disease, sickle cell disease, chronic kidney disease, and chronic liver disease have all been associated with zinc deficien

The highest concentrations of zinc are found in animal proteins with the number one concentration of zinc being found in oysters.  Exercising and excessive alcohol  intake decrease the levels of zinc in the body

Vitamins as well as trace elements like zinc can be deficient in the alcoholic population.  Our patient was found to be Vit A deficient as well.  The chart below reviews the findings in vitamin deficiencies and the one below that shows the amount of time it takes to become deficient in various vitamins.

Our patient suffered a coagulopathy with her malnutrition and had a retroperitoneal bleed with BP of 66 at one point. On CT blood was found in the R psoas muscles and bilateral iliacus muscles with active extravasation in the left iliacus.  She required emergent transfusion.  In the hospital she continued to have abdominal pain and poor po intake so TPN was started.  She remains hospitalized.

Foster M, Samman S. Zinc and regulation of inflammatory cytokines. Implications for cardiometabolic disease. Nutrients 4(7):676-94.

Suzuki H, Asakawa A, Li JB et al. (sept 2011) Zinc as an appetite stimulator-possible role of zinc in the progression of diseases such as cachexia and sarcopenia.  Recent patents of food, nutrition and agriculture 3(3):226-31.

Prasad AS (2003) Zinc deficiency: has been known of for 40 years but ignored by global health organizations BMJ 326(7386): 409-10.