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CASE PRESENTATION

CASE PRESENTATION. Mary Palomaki May 19, 2010. Chief Complaint. 16 month male with orange skin. History of Present Illness. Orange skin x 3 weeks Tugging on right ear Fever x 2 days, Tmax 102 PR Denies: change in activity, cough, runny nose, rash, vomit, diarrhea, travel, sick contacts

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CASE PRESENTATION

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  1. CASE PRESENTATION Mary Palomaki May 19, 2010

  2. Chief Complaint • 16 month male with orange skin

  3. History of Present Illness • Orange skin x 3 weeks • Tugging on right ear • Fever x 2 days, Tmax 102 PR • Denies: change in activity, cough, runny nose, rash, vomit, diarrhea, travel, sick contacts • Normal PO • Normal Stool • Normal in color, consistency • Normal UOP • Normal color

  4. Diet • 1 jar carrots/day • 1 jar mixed vegetables/day • Whole milk

  5. Birth History • Full Term • NSVD • No complications

  6. Past Medical History • Developmental Delay • Delayed Motor: Sit with support, no crawling, no walking • Delayed Speech: no words

  7. Family History • No thyroid disorders • No autoimmune disorders • No genetic disorders

  8. Vaccines • Delayed: No 1 year vaccines

  9. Physical Exam • VS: T: 101.3 HR: 120 RR 30 • O2Sat 100% RA • Gen: awake, alert • HEENT: NC, Perrl, EOMI, anicteric, mmm, oropharynx: no lesion, no erythema, R TM: + erythema, +bulging, L TM: dull • CV: S1, S2, no murmur

  10. Physical Exam 2 • Resp: b/l clear to ausculatation • ABD: BS+, soft, no distention, no HSM • Ext: FROM x 4, cap refill <2s • SKIN: orange/yellow tinged body, extremities, >>pigmentation palms, soles • GU: b/l descended testicles, normal phallus • Neuro: mild decreased tone, 2+ reflexes

  11. Differential Diagnosis

  12. Differential Diagnosis • Jaundice • Carotenemia • Excess ingestion/percutaneous absorption of chemicals • Quinacrine • Mepacrine • Dinitrophenol • Saffron • Tetryl • Picric acid • Inborn errors of metabolism

  13. Carotenemia • Increased number of carotinoids in the epidermis • Carotinoids are plant pigments • Act as antioxidants • Cell growth • Immune function • Carotene is hydrocarbon part of the carotinoid • Carotene from plants is primary dietary source of vitamin A

  14. Foods Rich in Carotene • Asparagus, broccoli, carrots, cucumbers, lettuce, spinach, squash, sweet potatoes, apples, oranges, peaches, prunes, tomatoes, yams, butter, egg yolk, milk, yellow corn • Baby foods and pureed foods allow greater absorption of carotene • Cell wall is broken during puree process, releasing carotene

  15. Carotene Metabolism Plant Cell Carotene Excretion via colon, epidermis In mucosal cells: B-carotene-->2 molecules retinol (Vitamin A metabolite) B-carotene 15, 15’dioxygenase

  16. Carotene • Accumulates in areas of concentrated sweat glands • Palms • Soles • Nasolabial folds • Is present in high concentration in breast milk

  17. Carotenemia • Mostly dietary • Associated with • Hypothyroidism • Diabetes Mellitus • Liver disease • Kidney disease • Anorexia Nervosa • Familial • Decrease amount of B-carotene 15, 15’dioxygenase

  18. Diabetes Mellitus • Most diabetics have elevated serum concentrations of B-carotene • Only 10% show skin color changes • Some diabetics have impaired conversion of B-carotene to retinol

  19. Hypothyroidism • Decreased conversion of carotene to Vitamin A • Hyperlipidemia and hypercholesterolemia exacerbate this effect

  20. Anorexia Nervosa • Altered lipid metabolism increases cholesterol levels, decreasing metabolism of carotene

  21. Carotene Absorption • Determined by type of food • Pureed foods • Manifest on skin 2 weeks after elevated serum levels of carotene

  22. History • Yellow/orange skin • No change in activity • No associated symptoms

  23. Diagnosis and Work Up • Clinical Diagnosis • No labs indicated

  24. Treatment • None • Anxious parents can be advised to avoid carotene containing foods

  25. Complications • None • Serum levels greater than three times the upper limit of normal do not cause hypervitaminosis A • Conversion of carotene to Vitamin A is slow

  26. NAME THAT DEFICIENCY/TOXICITY

  27. Pharyngeal ulcers • Impaired immunity • Megaloblastic anemia

  28. Folate deficiency

  29. Poor wound healing • Bleeding gums • Petechiae • Ecchymosis • arthralgia

  30. Vitamin C deficiency • (SKURVY)

  31. Pellagra--Niacin Deficiency • Diarrhea • Dermatitis • Dementia

  32. Anorexia • Dry/cracking skin • Hepatosplenomegaly • Long bone pain • Alopecia

  33. Vitamin A toxicity

  34. Bitot Spot

  35. Vitamin A Deficiency • Photophobia • Xerophthalmia • Keratomalacia • Epiphyseal bone formation • Defective tooth enamel • Retarded growth

  36. Fatigue • Anorexia • Irritability • Sometimes • Edema • Sometimes • No edema

  37. Beri-Beri(Thiamine) • Constipation • Headache • Insomnia • Polyneuritis • Elevated pyruvic • acid

  38. Photophobia, blurred vision

  39. Riboflavin (B2) deficiency • Burning, itching of eyes • Corneal vascularization • Poor growth • “Ariboflavinosis” • Phototherapy breaks down riboflavin • Careful with treatment of neonatal jaundice

  40. Patient eats diet of tomatoes and juice

  41. Lycopenemia • Lycopene found in tomatoes, beets, chili peppers • Turns skin reddish color, with excessive ingestion • Harmless condition • Resolves without treatment

  42. Oxaluria

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