Acquired zinc deficiency in an adult patient diagnosed by zinc therapy.

Dear Editor,

This is the report of a 67-year-old female patient presented with a history of perineal erythema and erosions for more than 14 days. In the last year, she was repeatedly hospitalized for chronic obstructive pulmonary disease, chronic pulmonary heart disease, and type 2 respiratory failure. During each hospitalization, she was given the following treatment: mechanical ventilation, semi-liquid diet, compound amino acid, and dipeptide medium/long-chain lipid emulsion injection for intravenous nutrition. Culture of the perineal region grew Candida albicans. Physical examination showed perineal erythema and erosion with creamy white discharge. The preliminary diagnosis was candidal intertrigo. The condition was treated with 1:20 betagen solution hydropathic compress and topical active ingredients for 1 week. The condition worsened with expansion of the perineal erythema and ulceration of part of the erosion (Figure 1). The tongue and side palate showed soybean-sized ulcers with erythema. The combination of perineal erythema and upper extremity erythema gave a final diagnosis of acquired zinc deficiency. Alkaline phosphatase level was normal, as well as serum zinc level. A nutritionist recommended 10 ml multitrace element injection (each 10 ml contains 6.5 mg of zinc) twice a day and gluconate solution 40 ml daily (each 10 ml contains 6.5 mg of zinc). However, we were only able to give the patient the multitrace elements injection and zinc gluconate 10 ml solution once a day because of the medicine cost and the presence of mouth ulcers. After 2 weeks of treatment, the ulcer became shallow and the discharge decreased. However, we observed several new large dark purple ecchymosis on the trunk and limbs. Routine blood test and blood coagulation showed no changes. With treatment following the recommended zinc dosage for 5 days, the ecchymosis on the trunk and limbs subsided, the ulcer healed, and the perineal erythema receded (Figure 2).

Figure 1

Papules and erythema with creamy white discharge on the vulva

Figure 2

Resolved erythema and secretion on the vulva, after treatment with zinc

Causes of acquired zinc deficiency include inadequate intake, parenteral nutrition, pregnancy and lactation, extensive burns, exfoliative dermatitis, intestinal malabsorption syndromes, cystic fibrosis, alcoholism, HIV infection, malignancies, and chronic renal disease.[1] Clinical manifestations may present as psoriasiform, annular, or crusted plaques, with decreased hair and nail growth.[2] Zinc levels either in plasma or serum are not reliable indicators for establishing a diagnosis of zinc deficiency. Normal values may be obtained in the presence of subclinical zinc deficiency. Therapeutic response in suspected cases remains the gold standard for diagnosis.[3]

The diagnosis of acquired zinc deficiency is often missed. In the present case, based on the fungus culture of Candida albicans, the patient was misdiagnosed with candidal intertrigo. The lesion showed no improvement with treatment based on antifungal shampoo and cream. Combining the history of fasting and perineal erythema, we changed treatment regimen to zinc based on the experience we had with another adult patient with acquired zinc deficiency due to long-term parenteral nutrition.[4] The recommended dosage of zinc is 2mg/kg/d, but the actual dosage is usually below that. In the present and previous cases, the average dosage was 0.68mg/kg/d and 0.12mg/kg/d, respectively.[4,5] Both patients responded well to treatment.

Our cases have all been inpatients, most of them with a history of parenteral nutrition or diarrhea. The main complaint reported was perineal erythema. On a detailed physical examination, acral erythema and paronychia could also be observed. Although our patients' zinc levels were normal, they all responded to zinc therapy. Inadequate dosing of zinc only partially improved the lesions. Increasing the dose led to the full resolution of the lesions, which underscores the importance of sufficient doses to confirm the diagnosis and to completely resolve the lesions.