S1432 Acrodermatitis Enteropathica-Like Dermatosis After Whipple Procedure

Abstract

INTRODUCTION: Zinc is a trace element which is involved in regulatory, catalytic, and structural functions of the body. It is mostly absorbed in the distal duodenum and proximal jejunum. Acrodermatitis enteropathica is an autosomal recessive disorder of zinc absorption leading to dermatosis. Pancreaticoduodenectomy or Whipple procedure, causes alterations in neuroendocrine hormone regulation, gastric emptying, and pancreatic secretions, leading to postsurgical nutritional deficiencies. CASE DESCRIPTION/METHODS: We present a 43-year-old female patient with a past medical history of insulin dependent type 2 diabetes mellitus, and surgical history of previous Whipple procedure for both chronic pancreatitis and a gunshot wound, who had presented to the hospital with a desquamating rash of her palms, soles, perineal and perioral area associated with significant pain. The patient was otherwise hemodynamically stable and afebrile. Dermatology was consulted and the patient underwent a skin biopsy, which revealed mild psoriasiform dermatitis with confluent parakeratosis. She tested negative for Celiac disease. Her zinc level came back at 49 ug/dl. The patient was started on supplemental IV zinc gluconate at 1mg/kg, which was transitioned to oral therapy upon discharge. Her dermatosis improved significantly following initiation of zinc repletion. Further blood work also revealed vitamins A, D, and E deficiency, which were replaced accordingly. DISCUSSION: Certain diseases and surgeries, such as the Whipple procedure, can lead to disruption of entero-pancreatic zinc circulation. Zinc deficiency can cause alopecia, acrodermatitis enteropathica-like skin eruptions, nail dystrophy, glossitis, night blindness, photophobia, and delayed wound healing. Zinc deficiency is primarily a clinical diagnosis. In patients with secondary zinc deficiency, increasing consumption of food enriched with zinc is typically the first step. Pancreatic enzyme supplementation often follows. IV zinc supplements may be necessary if there is no improvement with oral supplementation. Our aim is to increase physician awareness of dermatoses related to nutritional deficiencies in the setting of the Whipple procedure, since delayed diagnosis and treatment can lead to prolonged patient suffering.Figure 1.: Indentation across the fingernails also called Beau's lines.Figure 2.: Plantar skin desquamations.Figure 3.: Improved skin desquamation after zinc therapy.