27218632 Visualization

A 50 Age - year Age old Age man Sex with a history of metastatic Detailed_description mucinous Detailed_description appendiceal Disease_disorder adenocarcinoma Disease_disorder presents Clinical_event for evaluation of a desquamating Detailed_description rash Sign_symptom on his face Biological_structure that has spread to his scalp Biological_structure , inguinal Biological_structure region Biological_structure , and perineum Biological_structure over Duration the Duration past Duration 4 Duration months Duration (Figure 1).
The rash Sign_symptom has been accompanied by diffuse Detailed_description alopecia Disease_disorder of the face Biological_structure , scalp Biological_structure , axilla Biological_structure , and groin Biological_structure .
There was no improvement in the rash Sign_symptom despite multiple Dosage rounds Dosage of oral Administration fluconazole Medication , topical Administration antibiotic Medication ointment Administration , and intravenous Administration antibiotics Medication .
Prior to the development of his rash, he completed neoadjuvant Detailed_description chemotherapy Medication followed by surgical Therapeutic_procedure resection Therapeutic_procedure .
He underwent colostomy Therapeutic_procedure after he failed surgical Therapeutic_procedure correction Therapeutic_procedure for an enterocutaneous Disease_disorder fistula Disease_disorder , and he has required total Therapeutic_procedure parenteral Therapeutic_procedure nutrition Therapeutic_procedure ( TPN Therapeutic_procedure ) for the past Duration year Duration .
He did not notice any significant changes Sign_symptom in Sign_symptom ostomy Sign_symptom output Sign_symptom during this time.
Dermatological Diagnostic_procedure examination Diagnostic_procedure reveals widespread Detailed_description erythematous Detailed_description plaques Sign_symptom on the face Biological_structure , scalp Biological_structure , and medial Biological_structure aspect Biological_structure of Biological_structure thighs Biological_structure bilaterally Detailed_description and scattered Detailed_description papules Sign_symptom with scaling Detailed_description on face Biological_structure , scalp Biological_structure , chest Biological_structure , and back Biological_structure .
Diffuse Detailed_description , non Detailed_description - scarring Detailed_description alopecia Disease_disorder is present on the face Biological_structure , scalp Biological_structure , axillae Biological_structure , and groin Biological_structure .
The patient had acquired AE Disease_disorder , a rare dermatologic condition caused by zinc Disease_disorder deficiency Disease_disorder .
This patient developed acquired Detailed_description zinc Disease_disorder deficiency Disease_disorder in the setting of inadequate Lab_value zinc Medication supplementation Medication in TPN Therapeutic_procedure .
The patient had not received trace Medication elements Medication for approximately one Duration year Duration due to a national Other_event shortage Other_event .
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 Diagnostic_procedure level of 29 Lab_value ug/dL Lab_value (normal range 56-134 ug/dL).
He received zinc Medication supplementation Medication in his TPN Therapeutic_procedure , and within one Date month Date , the patient had complete resolution of rash Sign_symptom and fatigue Sign_symptom , and gradual return of hair Sign_symptom growth Sign_symptom (Figure 2).
Repeat zinc Diagnostic_procedure level Diagnostic_procedure following supplementation was 90 Lab_value ug/dL.
Although the patient recovered from his zinc Disease_disorder deficiency Disease_disorder , he later passed Outcome away Outcome .