Case Presentation: A 39 year old male with a history of alcohol abuse and recurrent methicillin resistant Staphylococcus aureus bacteremia was referred for tertiary evaluation of recurrent bacteremia and diffuse eczematous eruption. He reported chronic diarrhea and long standing eczema with significant worsening of his rash in the last few months. A scaly and painful rash with erosion around the thigh, buttock and perineal region was appreciated on exam (Image 1). Pertinent studies included a potassium of 3.3 mmol/L, calcium 8.5 mg/dL, WBC 17 K/uL, platelet 51 k/uL, alkaline phosphatase 182 U/L, albumin <1.5g/dL and pre-albumin 3 mg/dl. HIV and autoimmune workup negative. Plasma zinc level was 28mcg/dl (normal 60-130mcg/dl). Skin biopsy of the left thigh showed non-specific psoriasiform dermatitis with mild associated spongiosis. His rash worsened with extensive sloughing and exfoliation around the trunk, intertriginous areas and extremities.  It improved after two weeks of daily wet wraps, topical steroids and zinc replacement consistent with a severe eczematous flare with contributing zinc deficiency/AE. His hospital course was complicated by fungemia and worsening diarrhea.  EGD demonstrated villous blunting of the duodenal mucosa with acute and chronic inflammatory changes. Immunostaining was negative for CMV. The culmination of his clinical findings was consistent with zinc deficiency likely secondary to chronic alcoholism. 

Discussion: Zinc deficiency is associated with AE, a triad of alopecia, diarrhea as well as acral and periorificial dermatitis. More common in children, AE can also be seen in adults with a chronic malnutrition, alcoholism, liver disease, intestinal malabsorption, nephrotic syndrome as well burns or recent surgery. 1 Cutaneous manifestation is characterized by inflamed patches of dry red skin with blisters and pustules typically starting near an orifice and involving the urogenital region. Histopathological findings include confluent parakeratosis, psoriasiform hyperplasia, dermal edema, and perivascular lymphocytic infiltration but are non-specific. 2 Therefore, obtaining zinc levels is crucial. AE is associated with secondary staphylococcal, candidal and pseudomonal infections as well as pancytopenias. 1, 3, 4 Diarrhea is present due to villous atrophy and decreased brush border disaccharidase activity. 5 The clinical complexity of our medical surgical patients makes diagnosing AE difficult. Treatment with elemental zinc at a starting dose of 0.5–1 mg/kg/day can lead to improvement within weeks. This case highlights the wide spectrum of clinical manifestations associated with this nutritional deficiency and the need for hospitalists to maintain a high level of suspicion in their patient population.

Conclusions: This case illustrates the importance of considering AE in patients with alcohol consumption, chronic malnutrition and prolonged diarrheal illnesses, a population hospitalists encouter frequently. Early recognition and treatment is crucial as it portends a favorable prognosis