--- a
+++ b/processing/MACCROBAT/27218632.txt
@@ -0,0 +1,19 @@
+A 50-year old man with a history of metastatic mucinous appendiceal adenocarcinoma presents for evaluation of a desquamating rash on his face that has spread to his scalp, inguinal region, and perineum over the past 4 months (Figure 1).
+The rash has been accompanied by diffuse alopecia of the face, scalp, axilla, and groin.
+There was no improvement in the rash despite multiple rounds of oral fluconazole, topical antibiotic ointment, and intravenous antibiotics.
+Prior to the development of his rash, he completed neoadjuvant chemotherapy followed by surgical resection.
+He underwent colostomy after he failed surgical correction for an enterocutaneous fistula, and he has required total parenteral nutrition (TPN) for the past year.
+He did not notice any significant changes in ostomy output during this time.
+Dermatological examination reveals widespread erythematous plaques on the face, scalp, and medial aspect of thighs bilaterally and scattered papules with scaling on face, scalp, chest, and back.
+Diffuse, non-scarring alopecia is present on the face, scalp, axillae, and groin.
+The patient had acquired AE, a rare dermatologic condition caused by zinc deficiency.
+This patient developed acquired zinc deficiency in the setting of inadequate zinc supplementation in TPN.
+The patient had not received trace elements for approximately one year due to a national shortage.
+The key to the correct diagnosis of acquired AE is the combination of desquamating rash coupled with alopecia in the setting of chronic supplemental alimentation.
+Although it is reasonable to consider a skin biopsy, a skin biopsy would not definitively establish the diagnosis.
+A paraneoplastic panel could be considered, but it would delay diagnosis, and the presentation is most consistent with nutritional deficiency.
+It is not appropriate to start a topical steroid cream until a diagnosis is determined.
+The patient had a zinc level of 29 ug/dL (normal range 56-134 ug/dL).
+He received zinc supplementation in his TPN, and within one month, the patient had complete resolution of rash and fatigue, and gradual return of hair growth (Figure 2).
+Repeat zinc level following supplementation was 90 ug/dL.
+Although the patient recovered from his zinc deficiency, he later passed away.