Morning Report Visual diagnosis

1. Morning ReportVisual diagnosis Karen Estrella-Ramadan 07/09/12

2. Case 1 • 5mo 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 improvement • NOW: 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…..

3. Scaly, erythematous, crusty plaques vesicles

4. 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.

5. Pmhx: neg exc for some regression in language, Fhx: ezcema On PE: + gluteal wasting, enlarged BLaxillary and inguinal lymph nodes. Pustules, alopecia

6. Case 3 • 8 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: neg • On PE: HR: 150, <3% for wt, Ht, HC. Irritable, gralized weakness and…..

7. + Alopecia Pitting pretibialedema -also in scrotum and periorbital Erythematous, excoriated rash

8. Work up • CBC wnl, exc for borderline anemia • BMP, UA,, stool,Igs: negative • LFT wnl exc for case 2&3: hypoalbuminemia • CXR, US, celiac, TFT: neg • Alkaline phosphatase level low Case2:

9. Diagnosis Case 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). • acrodermatitisenteropathica-like skin eruption due to zinc deficiency in maternal milk. • Tx: pozn sulfate at 130 mg/day. • By 14 days no rash, no diarrhea, normal serum levels • Supplememented until 1 y/o

10. Diagnosis Case 2 • serum zinc is: 33 mcg/dL LOW • V25-OH vitamin D: low • CXR: ricketts • Zinc and ergocalciferol supplementation • acrodermatitisenteropathica • 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.

11. Diagnosis CASE 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

12. Zinc deficiency

13. Functions • metabolism of proteins, lipids, and carbohydrates • synthesis of nucleic acids, keep cell membrane • gene 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.

14. Deficiency • short stature • Hypogonadism • skin disorders including alopecia • cognitive dysfunction, impaired development • peripheral neuropathy • anorexia, diarrhea • platelet dysfunction • altered wound healing. • Impairement in humoral and cell-mediated immunity: candidal and gram-positive and gram-negative bacterial infections are common

15. 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).