Karen Estrella-Ramadan07/09/12

Morning ReportVisual diagnosis

Case 15mo M, exclusively BF, who presents with a 2 mo hx

of mild diarrhea, and perioral, facial, scalp and perineal skin Skin lesions 1st around the corners of mouth, back of

head and later perineum and buttock. Received: topical: abx, antifungal, steroids with little

improvementNOW: small blisters in hands and feet

Pmhx: bwt: 3.9kg, similar skin lesions, with the same distribution, appeared in an older brother when that brother was 4mo old. The older brother's rash resolved after he was weaned from BF.

PE: VS wnl, otherwise normal PE exc for…..

Scaly, erythematous, crusty plaques

vesicles

Case 2 8 mo AA, goes to ER with fever and worsening ezcema. He was diagnosed as having eczema at 3 wks old and was

breastfed exclusively until 4 months of age, when he was weaned. Since then, he has refused formula but will eat rice and oatmeal

cereal, baby foods that come in a jar, and table foods three times a day.

Since birth, his weight has dropped from the 75th percentile to below the 50th percentile.

For the past 4 months, he has vomited approximately 1 hour after each meal and passed seven to eight light brown, soft, formed stools each day. His hair is thinning, and his eczema has worsened. Four days ago, blisters appeared on his facial cheeks that, when ruptured, have a purulent discharge. His mother states that he has oral thrush and is eating and drinking less than usual. He now has a fever, with the temperature ranging from 101° to 102.8°F.

Pmhx: neg exc for some regression in language, Fhx: ezcemaOn PE: + gluteal wasting, enlarged BLaxillary and inguinal lymph nodes.

Pustules, alopecia

Case 38 mo M presents to clinic with 1wk hx of gralized edema. His last WCC was when he was 2mo old, when wt %50 and

had ezcema. His last visit to the clinic was at 3 months of age for

superinfected eczema that was treated with an oral antibiotic.

His eczema did not improve, he developed persistent diarrhea, and he did not return for medical attention until now. He developed generalized swelling of the extremities 1 week ago, and in the past 24 hours, his parents have noted severe swelling of the scrotum. Parents deny fever, vomiting, recurrent infections, or anorexia.

His diet consists only of human milk and fish broth because any other food causes increased eczema and diarrhea.

His mother also abstains from meats, vegetables, and dairy products because that diet increases the infant's eczema and diarrhea.

Pmhx: otherwise neg, Fhx: negOn PE: HR: 150, <3% for wt, Ht, HC. Irritable, gralized

weakness and…..

Pitting pretibial edema-also in scrotum and periorbital

Erythematous, excoriated rash

+ Alopecia

Work upCBC wnl, exc for borderline anemiaBMP, UA,, stool,Igs: negativeLFT wnl exc for case 2&3:

hypoalbuminemiaCXR, US, celiac, TFT: neg Alkaline phosphatase level low

Case2:

DiagnosisCase 1: Serum Zn: 22 LOW (70 to

150 mcg/Dl) and maternal human milk sampling demonstrates a low zinc concentration at 0.39 mg/L (normal, 0.95 mg/L).

acrodermatitis enteropathica-like skin eruption due to zinc deficiency in maternal milk.

Tx: po zn sulfate at 130 mg/day.

By 14 days no rash, no diarrhea, normal serum levels

Supplememented until 1 y/o

DiagnosisCase 2 serum zinc is: 33 mcg/dL

LOW V25-OH vitamin D: low CXR: ricketts Zinc and ergocalciferol

supplementation acrodermatitis

enteropathica He gains weight, his oral

thrush resolves, and he begins to feed spontaneously.

Discharge medications include oral zinc, ergocalciferol, multivitamins with iron, topical mupirocin, and oral clindamycin.

DiagnosisCASE 3: serum zinc concentration is 29.0

mcg/dL LOW elevated serum IgE concentration

at 3,864 IU/mL, egg white, peanut, soybean, and

wheat. Possible diagnoses include

protein allergy, malnutrition, protein-losing enteropathy, hypothyroidism, and zinc deficiency.

The patient is started on elemental formula and zinc supplementation; the parents choose to defer thyroxine administration.

By day 2, the edema and rash improve significantly, with almost complete resolution by day 7

Six months later: improvement in labs and clinically

Zinc deficiency

Functionsmetabolism of proteins, lipids, and

carbohydratessynthesis of nucleic acids, keep cell

membranegene regulation cofactor for more than 70 enzyme systems, Zinc plays a role in growth, tissue repair,

humoral and cell-mediated immunity, carbohydrate tolerance, and synthesis of testicular hormones.

Deficiencyshort statureHypogonadismskin disorders including alopeciacognitive dysfunction, impaired developmentperipheral neuropathyanorexia, diarrheaplatelet dysfunctionaltered wound healing. Impairement in humoral and cell-mediated

immunity: candidal and gram-positive and gram-negative bacterial infections are common

Recommended zinc intake: 12 mg/day (red meat, seafood, diary)

Absorbed in small bowel and stored in lover and kidney. Excreted in urine or stool. Fiver-cereal, corn, and rice decrease absorption

Zinc deficiency is sec to: inadequate intake, malabsorption, or excessive loss, alone or in combination, brought about by acquired or inherited conditions. < 5y/o: increased risk for diarrheal disease, pneumonia,

and malaria. milk protein sensitivity, Crohn disease, celiac disease,

sickle cell disease, cystic fibrosis, and liver and renal disease, protein-losing enteropathy (hypoalbuminemia and does not have underlying malnutrition, proteinuria, or liver disease).

BF exclusively sec to: abnormal Zn update by mmary gland, defection mmary excretion of lack of ligand in BM.

Preterm: zinc accumulation is greatest in the third trimester).