Acrodermatitis enteropathica-like dermatosis associated with combined deficiency of zinc and amino acids

Acrodermatitis dysmetabolica in an infant with maple syrup urine disease

Acrodermatitis dysmetabolica (AD) is a rare, newly termed, and poorly understood disease that appears to be clinically similar to acrodermatitis enteropathica (AE). Both diseases are characterized by the triad of periorificial and acral dermatitis, diarrhoea, and alopecia. Unlike AE, which is caused by zinc deficiency, AD is caused by numerous metabolic disorders. One such disorder is maple syrup urine disease (MSUD), a genetic deficiency of branched chain α-ketoacid dehydrogenase, the enzyme that degrades the branched-chain amino acids (BCAAs) isoleucine, leucine and valine. Treatment involves restricting BCAAs to prevent accumulation. We report a case of an infant being treated for MSUD, who developed the triad of AE/AD after a period of poor BCAA formula intake. The child was found to have low isoleucine and normal zinc levels. Increasing the isoleucine dose improved the eruption, thus the diagnosis of AD secondary to isoleucine deficiency was made. This case emphasizes the importance of carefully balancing BCAA levels while treating MSUD, as deficiency can precipitate AD.

Skin lesions in a 16-month-old toddler with impaired zinc absorption

Acrodermatitis enteropathica is a rare, autosomal recessive condition which results from impaired zinc absorption in the gastrointestinal tract. We report a 16-month-old female patient with a 7-month history of periorificial and acral skin lesions. Diagnosing of Acrodermatitis enteropathica was established on the basis of the patient's history as well as clinical and laboratory findings (a lowered zinc level in the child's serum: 17.2μg/dL (N 70-160 μg/dL)). Rapid clinical improvement was observed right after launching zinc supplementation.

Acrodermatitis enteropathica: an uncommon differential diagnosis in childhood - first description of a new sequence variant

An 11-month-old boy was brought to our clinic with superinfected, sharply-defined, symmetrical, erythematous macules and vesicles, some with yellowish-brownish crusts, on the cheeks, fingers, and in the diaper region. The suspected impetigo contagiosa had failed to respond to both topical antiseptic therapy and systemic antibiotics. Because of the unusual clinical picture and course, we measured the serum zinc level. A significantly reduced level of 2 μmol/l (normal range 9.2-18.4 μmol/l) was identified. Initial skin lesions had appeared one week after weaning (5th week after birth). Since the age of 8 months the infant had also had recurrent diarrhea. Two weeks after zinc-histidine substitution, the diarrhea ceased and skin lesions slowly disappeared. Molecular genetic testing for the SLC39A4 (zinc transporter) gene revealed compound heterozygosity for the previously unidentified mutations c.1465_1474+4del (p.?) and c.295G>A (p.Ala99Thr). The parents are healthy heterozygous gene carriers. The same compound heterozygosity was later detected in the newborn brother of our patient shortly after birth. A zinc deficiency could therefore be identified and treated before symptoms occurred. The inherited autosomal recessive zinc transporter deficiency is termed acrodermatitis enteropathica. Lifelong zinc substitution is recommended. A differential diagnosis can be difficult because bacterial and fungal superinfection is common in zinc deficiency. Precise diagnosis requires testing family members for the gene.

Acrodermatitis due to nutritional deficiency

PURPOSE OF REVIEW

Nutritional deficiency is prevalent in developing countries but should also be considered in developed countries in the setting of genetic or acquired disease states. The skin is commonly involved and is often one of the first organs affected in nutritional deficiency, providing a key to the diagnosis. This article will review the most common nutritional deficiencies causing a periorificial and/or acrodermatitis: zinc deficiency, biotin deficiency, kwashiorkor, and essential fatty acid deficiency.

RECENT FINDINGS

Whereas older literature has focused on the relationship among nutritional deficiency, malnutrition and poverty, recent research has identified additional patient populations that are at risk for developing nutritional deficiencies. These populations include premature infants, patients with long-term total parenteral nutrition, Crohn's disease, cystic fibrosis, intestinal bypass procedures, chronic alcoholics, anorexia nervosa, and restrictive diets. Recent studies have also focused on further understanding the genetic basis of inherited nutritional deficiencies such as acrodermatitis enteropathica.

SUMMARY

Skin manifestations can lead a provider to the diagnosis of a nutritional deficiency. In a child with a periorificial or acral dermatitis, the diagnosis of zinc, biotin, protein, or essential fatty acid deficiency should be considered, especially if accompanied by systemic signs of failure to thrive.