Transcript Visual dx1 7/9/12 Morning Report

Morning Report
Visual diagnosis
Karen Estrella-Ramadan
07/09/12
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…..
Scaly, erythematous,
crusty plaques
vesicles
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.
Pmhx: neg exc for some regression in language, Fhx: ezcema
On PE: + gluteal wasting, enlarged BLaxillary and inguinal lymph nodes.
Pustules, alopecia
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…..
+ Alopecia
Pitting pretibial edema
-also in scrotum and periorbital
Erythematous, excoriated rash
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:
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).
acrodermatitis enteropathicalike skin eruption due to zinc
deficiency in maternal milk.
Tx: po zn sulfate at 130 mg/day.
By 14 days no rash, no diarrhea,
normal serum levels
Supplememented until 1 y/o
Diagnosis
Case 2
serum zinc is: 33 mcg/dL LOW
V25-OH vitamin D: low
CXR: ricketts
Zinc and ergocalciferol
supplementation
 acrodermatitis enteropathica
 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.




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

Zinc deficiency
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.
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
 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).