A 30‐year‐old woman with history of obesity s/p gastric bypass 6 years ago presented for evaluation of hypoglycemia. Her initial day of hospitalization was for an elective calcium gluconate stimulalion study by interventional radiology. However, patient was admitted for several concurrent findings including sinus tachycardia to the 120s, severe anemia (hemoglobin 7.6 g/dL), anasarca, urinary retention, and generalized weakness. On review of systems, patient reported a cognitive decline over the past 2 years, worsening visual and auditory hallucinations, peripheral neuropathy, severe myalgias, intermittent diarrhea, loss of night time vision, and peeling dry skin and erythematous, hyperpigmented macules on the lower extremities for many months. Objective findings included an albumin of 1.4, an INR of 1.3 without significant transaminitis, and hemolytic anemia with undetectable haptoglobin. Evaluation revealed a normal liver ultrasound with vitamin K‐dependent factor V. Additional testing included a normal MRI brain, normal echo, and a nondiagnostic 72‐hour fast for hypoglycemia evaluation. Given her gastric bypass history, and lack of any multivitamin supplementation, testing for vitamins A, D, E, K, and trace minerals including copper and zinc levels was performed. This revealed profound deficiencies in all of Ihese essential vitamins and minerals.
This patient presented with findings consistent with symptoms consistent with essential vitamin and trace mineral defeciencies. Her hemolytic anemia and peripheral neuropathy, was likely from vitamin E deficiency. Vitamin K deficiency explained her elevated INR and low vitamin K‐dependent coagulation factors. Her Vitamin A deficiency accounted for night time vision loss. Additionally, her skin rash was likely from a combinalion of both a zinc and vitamin E deficiency. Zinc deficiency could have caused her psychoses. Both zinc and copper deficiencies contributed to her neurogenic bladder. Last, her copper deficiency contributed to her anemia, peripheral neuropathy, edema, and cognitive decline. Her hypoglycemic episodes were likely from dumping syndrome versus nesidioblastosis.
Postbypass malabsorptive stale can lead to severe essential vitamin and trace mineral defects. Subsequent multisystemic abnormalities such as those highlighted by this case can be corrected with replacement of essential vitamins and trace minerals. However, neurologic sequelae can be irreversible such as this patient's peripheral neuropathy.
A. Dave, none.