KWASHIORKOR ZINC DEFICIENCY OVERLAP FOLLOWING PARTIAL GASTRECTOMY/

A 48-year-old African-American woman presented with an eruption on her thighs, buttocks, and upper extremities of approximately 2 months dur ation. She also complained of diarrhea, poor appetite, weakness, and p ain around her mouth and eyes. Her medical history was significant for a gastrojejunostomy and stomach stapling for morbid obesity at the ag e of 32. The procedures resulted in a 500 lb weight loss over several years (from 600 lb to 106 lb). Her course was complicated by multiple bouts of diarrhea, inanition, and coma. Physical examination demonstra ted sharply demarcated plaques of dusky erythema, with superficial des quamation and a ''cracked enamel'' appearance, over the upper extremit ies, buttocks, and extending to the lateral aspects of the thighs (Fig . 1). Erythema and crusting were noted at the comers of her mouth, and a few small crusts were apparent over the medial aspect of the left u pper lid margin. No intraoral, periungual, or perianal abnormalities w ere noted. No hair abnormalities were appreciated. Initial laboratory data included a complete blood count (CBC), chemistry profile, and lev els of magnesium, vitamin B12, folic acid, total iron, glucagon and zi nc. Abnormal laboratory values included total serum protein 5.5 g/dL ( normal, 6.0-8.2 g/dL), albumin 2.2 g/dL (normal 3.5-5.0 g/dL), and ser um zinc 30 mu g/dL (normal, 60-130 mu g/dL). A biopsy from the left hi p (Fig. 2) revealed dense parakeratotic scale with an irregularly acan thotic epidermis. Foci of minimal spongiosis were noted. Superficially , the keratinocytes were large and pale. Within the dermis, papillary dermal edema, scattered extravasated erythrocytes, and a superficial, perivascular, mononuclear infiltrate were noted.