Malnutrition dermatosis following adrenal insufficiency in an adult

Sir,

A 26-year-old man presented to the dermatology outpatient department of the All India Institute of Medical Sciences, Bhubaneswar, with redness and peeling of skin on the trunk and buttocks, blisters on the legs along with weakness, head reeling, vomiting and decreased appetite for 1 month. General examination revealed severe pallor, pitting acral edema and low blood pressure (90/60 mmHg). On cutaneous examination, there were multiple erythematous plaques with scaling on the hands, thighs, buttocks, legs and back of the trunk [Figures 1 and 2]. Vesicles and bullae were present on a background of patchy erythema with oozing on the lower extremities [Figure 3]. Multiple petechiae and perifollicular hemorrhage were present on the thighs, legs and hands [Figure 4]. Oral examination showed angular cheilitis and bald tongue. Systemic examination was unremarkable. Based on the history and examination, he was suspected of having zinc, vitamin C and iron deficiency. His routine investigations showed hemoglobin of 6 g/dl, decreased mean corpuscular hemoglobin concentration (MCHC) and mean corpuscular volume (MCV) (29 g/dl,78 fL), serum sodium - 116 mEq/L (N: 135–145 mEq/L), serum albumin - 2.8 g/dl (N: 3.4–5.4 g/ dl), serum alkaline phosphatase - 38 U/L (N: 40–115 U/L) and serum zinc - 16 mcg/dl (N: 54–151mcg/dl). Peripheral smear revealed microcytic hypochromic anemia. Serum ferritin was 23 ng/dl (N: 20–500 ng/dl) and serum iron was 68 mcg/dl (N: 60–170 mcg/dl). Serum vitamin D (44 ng/mL), serum calcium (9.3 mg/dL), serum fasting and postprandial glucose levels (94 mg/dL, 120 mg/dL) were normal. Skin biopsy from the bullae on the left lower leg showed psoriasiform epidermal hyperplasia, spongiosis, intracorneal bullae and vacuolar changes [Figure 5]. He was started on oral zinc 5 mg/kg/day, vitamin C and sodium chloride 3% injection. Two units of blood transfusion and one unit of albumin infusion were given along with oral iron and protein supplementation. Following sodium supplementation (3% sodium chloride injection at 10 ml/h), the sodium level increased up to 128 mEq/L in 2 days but again dropped to 120 mEq/L. There was no consistent improvement in hyponatremia, head reeling, vomiting and hypotension. Ultrasound abdomen and pelvis, chest X-ray and computed tomography scan of thorax and abdomen were normal. Mantoux test was negative. On repeated enquiry, there was a history of self-medication with oral prednisolone for joint pain for one year which he stopped one month back following which systemic symptoms appeared. Serum cortisol at 8 am was 3.36 mcg/dl (6–23 mcg/dl). Diagnosis of exogenous adrenal insufficiency with malnutrition dermatosis was made. He was restarted on prednisolone 20 mg/day by the endocrinologist. After three weeks, all symptoms and skin lesions improved [Figure 6]. However he continued the treatment with endocrinologist for his adrenal insufficiency.

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Figure 1:

Erythematous plaques with scaling on the buttocks

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Figure 2:

Erythema with scaling on the trunk

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Figure 3:

Patchy erythema, vesiculation with oozing on lower extremities

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Figure 4a:

Multiple petechiae and perifollicular hemorrhage over thighs

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Figure 4b:

Close view of prominent perifollicular hemorrhages over thigh

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Figure 5a:

Scanner view showing epidermal hyperplasia, acanthosis, elongation of rete ridges, vacuolization and bulla in stratum corneum (H and E stain, ×40)

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Figure 5b:

High-power view showing bulla with a few scattered lymphocytes and red blood cells, mild spongiosis and microvesiculation in the epidermis (H and E stain, ×400)

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Figure 6a:

Improvement of skin lesions after 1 month of treatment with zinc and vitamin C on the trunk

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Figure 6b:

Improvement of skin lesions after 1 month of treatment with zinc and vitamin C on the thighs

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Figure 6c:

Improvement of skin lesions after 1 month of treatment with zinc and vitamin C on the buttocks

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Adequate amount of nutrients is necessary for functioning of different organs and various metabolic processes. Acquired nutritional deficiency in adults is commonly caused by malabsorption, inadequate intake, malignancy, tuberculosis, following gastric surgery and those on parenteral nutrition.^1,2 It is rarely described with adrenal insufficiency. Deficiencies of nutrients such as zinc, iron and vitamin C clinically manifests as eczematous dermatitis and psoriasiform plaques predominantly involving the frictional areas, glossitis and angular chelitis, and perifollicular hemorrhages, respectively.^3-5 The symptoms of adrenal insufficiency include chronic, fatigue, muscle weakness, loss of appetite, weight loss, abdominal pain, nausea, vomiting, diarrhea, low blood pressure, irritability and depression.⁶ Our case had cutaneous features suggestive of zinc, vitamin C and iron deficiency. Hemoglobin, serum zinc, iron and ferritin levels were low. We could not establish vitamin C deficiency due to unavailability of facility in our institute. Our case also had edema on extremities due to hypoalbuminemia which responded to albumin infusion and oral protein supplementation. Absorption of zinc requires albumin. Hence, serum albumin should be restored to normal level to facilitate zinc absorption, and for the same reason, higher dose of zinc is required in case of low serum albumin. His skin lesions improved within two weeks of therapy with high dose of zinc (5 mg/kg body weight). However, systemic symptoms such as head reeling, weakness, vomiting and decreased appetite persisted. Tuberculosis was ruled out by normal chest X-ray, erythrocyte sedimentation rate and negative Mantoux test. Screening for malignancy was negative with normal computed tomography scan of thorax and abdomen. Diagnosis of adrenal insufficiency was confirmed by low serum cortisol level. All his symptoms due to adrenal insufficiency improved with exogenous prednisolone supplementation. The case is being reported to increase the awareness among dermatologists to keep in mind exogenous adrenal insufficiency as one of the causes of malnutrition dermatosis. Furthermore, this case highlights the clinical manifestations of zinc, vitamin C and iron deficiency altogether in a young adult which is rarely documented nowadays.