Unexpected hypozincaemia in a patient with discharging empyema that proved resistant to replacement therapy.

A 45-year-old man was admitted with a massive discharging empyema. He had severe chronic malnutrition and was noted to be zinc and selenium deficient. A high-calorie oral diet supplemented with iron, zinc and selenium was started, together with antibiotic therapy and continued prescription of the patient's regular medication, including a PPI (proton pump inhibitor). Although selenium increased to normal levels after 4 weeks of supplementation, zinc levels failed to normalise. Antibiotic therapy improved the empyema and a steady increase in weight was achieved. The patient was noted to have erythematous skin lesions, hair loss and reduced wound healing, all of which may be attributable to zinc deficiency. We propose that competition for intestinal absorption of nutrients and the use of a PPI may have covertly contributed to the inability to normalise serum zinc levels in this case.