A 54‐year‐old alcoholic homeless man was brought to the hospital by EMS after being found intoxicated on the street. Of interest, the patient used adult diapers in lieu of underwear while homeless. His medical history was significant for TB treated 1 year prior to admission, and he adhered to a multidrug regimen for 6 months. On exam he was thin, disheveled, and smelled strongly of alcohol. His skin was notable for confluent patches of an erythematous, ulcerative rash covering the buttocks and perineum. Laboratory studies were remarkable for chronically low to low‐normal alkaline phosphatase of 51–58 U/L and hemoglobin of 8.4–10.4 g/dL. Because of the unusual distribution of the rash, a zinc level was checked and came back to be 36 μg/dL (normal range, 60–130 μg/dL), altogether leading to a diagnosis of zinc deficiency. Treatment with zinc supplements was initiated with great improvement of the patient's rash over several weeks.
Zinc deficiency is a global health issue affecting up to 2 billion people. Acrodermatitis enteropathica is a rare autosomal recessive disorder characterized by an impairment of zinc absorption. Acquired zinc deficiency may be due to decreased absorption of zinc in conditions such as inflammatory bowel disease, cystic fibrosis, and malabsorption syndromes; increased renal excretion as in nephrotic syndrome or alcoholism; inadequate dietary intake as seen in anorexia nervosa and total parenteral nutrition; or in increased demand states such as pregnancy and lactation. Cutaneous presentation ranges from annular and psoriasiform plaques or lichenoid lesions in mild deficiency to scald‐like erythema, fissuring and eczematous lesions with bullae in severe cases. The lesions develop acutely around orifices and on dependent areas. Plasma zinc levels may not correlate with zinc status; however, given the lack of other biomarkers, low plasma levels remain the gold standard for detecting zinc deficiency. Additionally, serum levels of alkaline phosphatase, a zinc‐dependent enzyme, can be measured as they correspond to zinc status. Treatment is with zinc by enteral or parenteral replacement depending on the cause of the deficiency, leading to rapid clinical improvement.
Zinc deficiency has been recognized as an important nutritional deficiency for decades, yet much of the focus was on the pediatric population due to its association with diarrhea, dermatitis, and overall childhood morbidity and mortality. Zinc deficiency in adults has a similar presentation and should not be overlooked. This case demonstrates zinc deficiency should be included in the differential for adult patients presenting with an ulcerative rash in the diaper distribution area, especially in the context of active alcoholism, recent treatment with isoniazid associated with atrophic gastritis or the presence of other malabsorptive states.
To cite this abstract:Raza Y, Averbukh Y. Presentation of Zinc Deficiency As a Perianal Ulcerative Rash in an Alcoholic Man. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 409. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/presentation-of-zinc-deficiency-as-a-perianal-ulcerative-rash-in-an-alcoholic-man/. Accessed April 4, 2020.