Failure to thrive presenting with an unusual skin rash

‘Peeling paint’ dermatitis as a presenting sign of cystic fibrosis

Presentation of cystic fibrosis with a rash is rare, with only 19 previously reported cases. This unusual presentation is associated with false negative sweat tests, delays in diagnosis and considerable mortality. Multiple nutritional deficiencies, the aberrant production of prostaglandins and free-radical mediated damage have been implicated in the pathogenesis of this kwashiorkor-like dermatitis. In spite of the rarity of this presentation, recognition of the rash is important, not only to expedite the diagnosis, but also to gain insight into the disease. We present a further case to highlight this unusual presentation and discuss potential pathophysiological mechanisms.

Edema, anemia, hypoproteinemia, and acrodermatitis enteropathica: an uncommon initial presentation of cystic fibrosis

Cystic fibrosis is a genetic disorder characterized by chronic obstructive pulmonary disease, pancreatic exocrine deficiency, and abnormally high sweat electrolyte concentrations. Less frequently, the presenting features in infants may include edema, anemia, hypoproteinemia, and acrodermatitis enteropathica. Liver involvement may produce hepatomegaly and mild elevation of transaminases. This clinical symptom usually presents within the first 6 months of life and is associated with a high morbidity and mortality. Early recognition and institution of appropriate nutritional supplementation and pancreatic enzymes is essential to improve outcome. Since the sweat test may be falsely negative, emergency physicians must maintain a high index of suspicion to make the diagnosis of cystic fibrosis in an infant who presents with edema, anemia, hypoproteinemia, and acrodermatitis enteropathica.

Plasma and red blood cell zinc in cystic fibrosis

The objectives of this study were to measure plasma and red blood cell (RBC) zinc concentrations in patients with cystic fibrosis (CF), and examine their relationship to nutritional status and pulmonary function. Plasma and RBC zinc levels were compared in 53 CF patients ranging in age from 0.5-46 years. Their relationships to weight (% ideal weight) and forced expired volume in 1 sec (FEV(1)) (% predicted value) were examined. After excluding improperly handled specimens, RBC zinc levels in 51 patients and plasma zinc concentrations in 40 patients were included for analysis. Sixteen of 51 (31%) patients had low RBC zinc levels compared to 4 of 40 (10%) with low plasma zinc concentrations (P < 0.01). Thirteen of 38 patients (34%) in whom both values were obtained had low RBC zinc concentrations compared to 4 of 38 (11%) with low plasma zinc levels (P < 0.022). Neither low RBC nor plasma zinc levels correlated with nutritional status or lung function. In conclusion, about one third of patients with CF had low RBC zinc levels. Plasma zinc concentrations may not adequately reflect overall zinc status. This deficiency did not appear to be related to either nutritional status or lung function. The significance of low RBC zinc in CF is unknown.

[Zinc deficiency in mucoviscidosis]

Zinc deficiencies can induce dermatitis in subjects presenting cystic fibrosis.

CASE REPORT

A patient, Clement, presented with a digestive form of cystic fibrosis. At four months of age, he presented a dermatitis similar to acrodermatitis enteropathica. Early clinical diagnosis and treatment led to a rapid response to zinc sulfate therapy.

DISCUSSION

Less intestinal absorption, malnutrition, and diet are just some of the numerous reasons for the zinc deficiency in this case. Biological support is not necessary to begin the treatment.

Malnutrition-associated rash of cystic fibrosis

Rash is a rare presenting sign of cystic fibrosis (CF) complicated by protein-calorie malnutrition. We measured essential fatty acid (EFA) levels in the serum of a 4-month-old girl with an erythematous, desquamating, periorificially accentuated rash in association with malnutrition and her 2-year-old sister who was diagnosed concurrently with CF but had no rash or signs of malnutrition. Both patients had biochemical evidence of EFA deficiency, suggesting that development of the rash is multifactorial. Clinical presentation, management, and possible modes of pathogenesis of the rash are reviewed. Pathogenesis of the rash appears to involve a complex interaction among deficiencies of EFAs, zinc, protein, and possibly copper, leading to disordered prostaglandin metabolism or cytokine production, or free radical-induced damage to cellular membranes due to a lack of nutrient-derived protective antioxidants.

Cystic fibrosis presenting as kwashiorkor with florid skin rash

Two infants with a florid erythematous rash and generalised oedema, hypoalbuminaemia, and anaemia were found to have cystic fibrosis. This rare presentation is associated with false negative sweat tests, delays in diagnosis, and a considerable mortality. It is proposed that this presentation represents a manifestation of kwashiorkor secondary to malabsorption. The recognition that these infants have kwashiorkor provides some insight into the pathogenesis and management of their illness.

Cystic fibrosis presenting with periorificial dermatitis

A 2-week-old baby boy had a periorificial dermatitis that progressively worsened, as did his failure to thrive. Decreased serum zinc, proteins, and amino acids, as well as an increase in fecal fat, were noted. The child's dermatitis responded promptly to nutritional therapy. Sweat chloride levels were markedly elevated. The dermatitis, occasionally seen as a presenting feature of cystic fibrosis, is most likely the result of malabsorption caused by pancreatic exocrine dysfunction.

Clinical and laboratory diagnosis of acrodermatitis enteropathica

Acrodermatitis enteropathica is an inborn error of metabolism resulting in zinc malabsorption and severe zinc deficiency. From personal experience and a literature review the following conclusions were drawn: 1. Symptoms other than dermatitis, vary with age. Diarrhoea, mood changes, anorexia, and neurological disturbance were reported most frequently in infancy. Growth retardation, alopecia, weight loss and recurrent infections were prevalent in toddlers and schoolchildren. Spontaneous remission may occur at adolescence. 2. The severity of symptoms also varies. Intermittent or mild cases of the disease and those presenting with uncommon features such as ophthalmic, cerebral or hepatic involvement, are easily overlooked. In the severe cases this may result in a fatal outcome. If untreated, the overall mortality rate is 20%, being higher in males. 3. The laboratory diagnosis is hazardous. In patients, mean zinc values in serum, urine and hair were ca. 50% of normal levels. There is a 15% overlap with healthy controls; moreover, low zinc levels in serum, urine or hair are also found in other diseases. A more specific test is required. 4. In cases of doubt, in vitro or in vivo zinc absorption tests using radioisotopes (65Zn or 69mZn) may be performed. These appear not to be influenced by other conditions and show less overlap with controls. If such tests are unavailable, the clinical response to 3-30 mumol zinc/kg per day for 5 days may be awaited. This is recommended in infants or children with one or more symptoms of acrodermatitis enteropathica.

A new recessive syndrome of unusual facies, digital abnormalities, and ichthyosis

Two sibs with a similar pattern of unusual facial features, limb malformations, and postnatal onset of ichthyosis are reported. The parents are first cousins and neither shows any stigmata of the disorder. The presence of ichthyosis suggests that there may be a metabolic component to this syndrome. In view of the consanguinity and pattern of the malformations, autosomal recessive inheritance seems likely.