A 42-year-old man with a history of Crohn disease comes to the office for follow-up. He had a partial ileal resection due to a stricture and also had multiple surgeries to treat an enterocutaneous fistula. The patient has received parenteral nutrition for the past several weeks and recently restarted oral feeding. He reports nonbloody diarrhea but no fever or abdominal pain. The patient says that food does not taste the same as before. On examination, he has patchy alopecia and a pustular, crusting skin rash with scaling and erythema around the mouth and on the extremities. No abdominal tenderness is present and bowel sounds are normal. The jugular venous pulse is normal and there is no lower extremity edema. Which of the following is most likely to improve this patient's current condition?

Question

A 42-year-old man with a history of Crohn disease comes to the office for follow-up.  He had a partial ileal resection due to a stricture and also had multiple surgeries to treat an enterocutaneous fistula.  The patient has received parenteral nutrition for the past several weeks and recently restarted oral feeding.  He reports nonbloody diarrhea but no fever or abdominal pain.  The patient says that food does not taste the same as before.  On examination, he has patchy alopecia and a pustular, crusting skin rash with scaling and erythema around the mouth and on the extremities.  No abdominal tenderness is present and bowel sounds are normal.  The jugular venous pulse is normal and there is no lower extremity edema.  Which of the following is most likely to improve this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d820_1262_bc81_b7a894f0f555_MD0003_00 This patient most likely has zinc deficiency. Zinc is a trace mineral that is obtained from meat, nuts, and fortified cereal in the diet. It is an essential component of numerous enzymes in the body and plays an important role in gene transcription and cell division. Clinical manifestations of zinc deficiency in adults include hypogonadism, impaired wound healing, impaired taste, and immune dysfunction. Characteristic physical examination findings include alopecia as well as a skin rash consisting of erythematous pustules around body orifices (eg, mouth) and on the extremities. Zinc is absorbed mostly in the duodenum and jejunum, and deficiency can be due to malabsorption (eg, Crohn disease, celiac disease), bowel resection, gastric bypass, or poor nutritional intake. In addition, patients dependent on parenteral nutrition (PN) are at risk for trace mineral deficiency (eg, zinc, selenium, copper, chromium) due to inadequate supplementation of parenteral intake. Comorbid diarrhea and malabsorption further increase the risk of trace mineral deficiency in patients on PN due to excessive gastrointestinal losses. (Choice A) Clinical manifestations of copper deficiency include fragile hair, skin depigmentation, neurologic dysfunction that can mimic vitamin B₁₂ deficiency, and sideroblastic anemia. Impaired taste and a pustular skin rash would be unusual. (Choice B) Gluten avoidance is used to treat celiac disease, which can lead to malabsorption and deficiency of zinc and other vitamins and minerals. Celiac disease is associated with dermatitis herpetiformis, an autoimmune-mediated vesicular skin rash that typically appears on the extremities. Perioral involvement would be unusual. In addition, celiac disease is less likely in this patient with alternate explanations for zinc deficiency (eg, Crohn disease, recent PN). (Choice C) Niacin (vitamin B₃) deficiency (rare in developed countries) causes pellagra, which is characterized by dermatitis, diarrhea, and dementia. The rash associated with pellagra is hyperpigmented, occurs symmetrically in sun-exposed areas, and is not pustular. (Choice D) Selenium deficiency can lead to thyroid dysfunction as well as cardiomyopathy. The absence of heart failure signs (eg, jugular venous distension, lower extremity edema) in this patient makes selenium deficiency less likely. Educational objective: Risk factors for trace mineral deficiency include malabsorption, bowel resection, poor nutritional intake, and dependence on parenteral nutrition. Clinical manifestations of zinc deficiency include hypogonadism, impaired taste, impaired wound healing, alopecia, and skin rash with perioral involvement. References: Zinc: physiology, deficiency, and parenteral nutrition. (http://www.ncbi.nlm.nih.gov/pubmed/25681484)

A 42-Year-Old Man with a History of Crohn Disease Comes