Zinc Deficiency Syndrome?

Abstract:  53 yo woman with one month history of wide-spread dermatitis.

HPI:  The patient is a massively obese woman who weighed 750 pounds a year before her office visit but at present weighs around 350 pounds.  Her weight loss has been achieved by severe calorie restriction (she lives in a care facility).  Her skin was clear until a month before the office visit.  By history, the dermatitis began on hands and arms, spread to skin folds, postauricular areas and angles of mouth.  She has had some diarrhea.

O/E:  The patient appeared alert, tired and massively obese. She had a papulosquamous eruption on arms consisting of erythematous patches with fine superficial scale.  There was erythema in all examined skin folds with mild serous discharge.  She had an erosive postauricular dermatitis and angular cheilitis (see photo).  Dental hygiene was good and KOH prep from angle of mouth showed very rare yeast forms.

Clinical Photo:

Lab:  Post auricular culture grew Staph aureus (MRSA) and Pseumonas.  Serum zinc 0.58 mcg/ml (normal 0.66 - 1.1 mcg/ml)

Biopsy from arm lesion showed orthokeratosis, subcorneal neutrophils, focal hypogranulosis and psoriasiform hyperplasia consitent with psoriasis or given her history acrodermatitis enteropathica.

Diagnosis:  The short history of dermatitis here suggests a nutritional etiology may be considered.  This woman had no history of skin disease until a month before her office visit.  She had been on a very restrictive diet and it is unclear how carefully vitamins and micronutrients had been monitored.  The low zinc level may not be the only deficiency she has.  Her MRSA should be addressed, but low zinc may have set up a situation where MRSA could thrive in skin folds (an altered skin microbiome).

Questions and Comments:  This is a complex case and it is unlikely that sinc supplements will address all of this woman's needs.  A nutritionist may help.  The angular cheilitis was a clue to "think zinc."  Her MRSA needs to be addressed as well as the intertrigo.  She is relatively young and healthy. Considering her obesity, a multidisciplinary approach could help her.  In the setting of a group home this may not be forthcoming.  Patients like this can be marginalized in any health-care setting and present diagnostic and management problems.  There are many more questions?  What did her hemogram show?

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The Rudolph Sign

Abstract: 81 year old man with new onset of a red nose

HPI :  This 81 yo man presented with a one day history of a painful inflammatory process of his nose.  He had been in hospital recently and a routine throat culture grew MRSA but since he was asymptomatic, it was not treated. He has atrial fibrillation and meds include warfarin.  Here is the history in his own words.

O/E:  The examination shows an erythematous, slightly indurated area around the bulb of the nose.  

IMPRESSION:  With a history of MRSA and the clinical appearance this looks like nasal vestibular furunculosis as described recently in the dermatologic literature by Dahle andSontheimer.  

Course: He was treated with mupirocin ointment applied intranasally, but after three days there was no change and the process was somewhat worse.  Initially he graded the pain in the nose as a "7" and after three days as a "9" on the Pain Scale of 0 - 10. A culture was taken from the nares and he was placed on minocycline as Bactrim is contraindicated with warfarin.  He was admitted to hospital later that day for uncontrolled atrial fibrillation and  treated with i.v. vancomycin for two days until the preadmission culture came back negative.  Discharged home after two days a papule appeared on the bulb of the nose which drained serosanguinous material and the process started to resolve.  Repeat culture was taken (no pathogens).  When seen at Day 14, he showed marked improvement and he rated his pain as a "O."

Comments:  Nasal vestibular furunculosis (NVF) was described by Dahle and Sontheimer.  They recommended intranasal application of mupirocin with Q-tip applicators.  Our patient did not respond to that which suggests that NVF may need more aggressive therapy in some cases.  We did not perform an initial culture since he'd had one before, but in retrospect we should have done that.  For the clinician, one needs to consider the rare occurrence of cavernous sinus thrombosis with infections of the central face.  The literature on NVF is sparse and most articles lack abstracts.  This area needs more attention as NVF may not be as uncommon as the literature suggests.

Clinical Photos:  

Day i

Day 4

Day 7

Day 14

Day 21

Reference:

1. Dahle KW, Sontheimer RD. The Rudolph sign of nasal vestibular furunculosis: questions raised by this common but under-recognized nasal mucocutaneous disorder.  Dermatol Online J. 2012 Mar 15;18(3):6.  Free Open Access

2. Laupland KB, Conly JM. Treatment of Staphylococcus aureus colonization and prophylaxis for infection with topical intranasal mupirocin: an evidence-based review.

Clin Infect Dis. 2003 Oct 1;37(7):933-8. Epub 2003 Sep 8.  Email: laupland@calgaryhealthregion.ca

Abstract: Most Staphylococcus aureus infections are endogenously acquired, and treatment of nasal carriage is one potential strategy for prevention. We critically appraised the published evidence regarding the efficacy of intranasal mupirocin for eradication of S. aureus nasal carriage and for prophylaxis of infection. Sixteen randomized, controlled trials were appraised; 9 trials assessed eradication of colonization as a primary outcome measure, and 7 assessed the reduction in the rate of infection. Mupirocin was generally highly effective for eradication of nasal carriage in the short term. Prophylactic treatment of patients with intranasal mupirocin in large trials did not lead to a significant reduction in the overall rate of infections. However, subgroup analyses and several small studies revealed lower rates of S. aureus infection among selected populations of patients with nasal carriage treated with mupirocin. Although mupirocin is effective at reducing nasal carriage, routine use of topical intranasal mupirocin for infection prophylaxis is not supported by the currently available evidence. Free Open Access.

3. Dr. Richard Sontheimer sent us this article which may explain why our patient did not respond to mupirocin.  This is a sobering article -- one wonders if resistance patterns elsewhere are as high or whether this was uniqueto the burn center in Tehran.
Burns, 2012 vol. 38(3) pp. 378-82
A high prevalence of mupirocin and macrolide resistance determinant among Staphylococcus aureus strains isolated from burnt patients.
Shahsavan, et. al.  (Tehran University of Medical Sciences)
Abstract: Infections due to Staphylococcus aureus have become increasingly common among burn patients. The antibiotic resistance profile of S. aureus isolates and inducible resistance against clindamycin were investigated in this study. The presence of mecA gene, mupA gene and macrolide resistance genes were detected using PCR and multiplex-PCR. The resistance rate to methicillin, erythromycin and mupirocin were 58.5%, 58% and 40%, respectively. The prevalence of constitutive and inducible resistance among macrolide resistant isolates was 75% and 25%, respectively. Ninety five percent of the isolates were positive for one or more erm genes. The most common genes were ermA (75%), ermC (72%) and ermB (69%), respectively. The ermA gene predominated in the strains with the inducible phenotype, while ermC was more common in the isolates with the constitutive phenotype. The msrA gene was only found in one MRSA isolate with the constitutive phenotype. A total of 27 isolates (25%) carried the mupA gene. All the mupirocin resistant isolates and almost all the erythromycin resistant isolates were also resistant against methicillin which may indicate an outbreak of MRSA isolates with high-level mupirocin and erythromycin resistance in the burn unit assessed.

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