Contributed by Mark Malone, M.D. and Kevin J. Flynn, M.D.
Published on line in July 1996
This is a 38-year old woman with a history of morbid obesity who, in 1986, underwent a gastric bypass, which subsequently required revision. She underwent a pancreatico-duodenal diversion in March of 1994. She has a history of sleep apnea, asthma, and hypothyroidism. She was admitted to the University of Pittsburgh Medical Center (UPMC) in December of 1995 because of diarrhea and protein-calorie malnutrition requiring total parental nutrition.
She was readmitted to the UPMC in May of 1996, complaining of increasing fatigue, sore throat, mouth and tongue, and a red itchy rash of the extremities of two weeks duration. Her diet history consisted mostly of carbohydrates and vegetables, with little meat. At that time she had chronic diarrhea of four to five stools per day.
She had a dry oral mucosa, a beefy red tongue, an erythematous throat without exudates, angular stomatitis bilaterally, and ascites. The skin displayed a blanching maculopapular scaling rash on the extremities with some punctate erythematous lesions. Laboratory studies showed a total protein deceased to 4.4 g/dL (normal 6.3-7.7), with 1.7 g/dL of albumin (normal 3.5-5.0). Vitamin A and E were decreased at 14.6 mg/dL (normal 30-80) and at 4.5 mg/dL (normal 5.1-13.7) respectively.