566465
research-article2015
PENXXX10.1177/0148607114566465Journal of Parenteral and Enteral NutritionSant et al
Case Report
Zinc Deficiency With Dermatitis in a Parenteral Nutrition–Dependent Patient Due to National Shortage of Trace Minerals
Journal of Parenteral and Enteral Nutrition Volume XX Number X Month 201X 1–4 © 2015 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0148607114566465 jpen.sagepub.com hosted at online.sagepub.com
Vivek R. Sant, BA1; Tracey D. Arnell, MD2; and David S. Seres, MD, ScM3
Abstract The shortages of intravenous drugs remains critical, with sterile injectables accounting for 80% of the approximately 300 shortages. The impact is being felt in patients dependent on parenteral nutrition (PN), and severe deficiencies are becoming more commonplace. We report here a man who developed severe zinc deficiency, manifesting as a painful desquamative rash, due to an inability to obtain multi–trace element additives for his PN. (JPEN J Parenter Enteral Nutr. XXXX;xx:xx-xx)
Keywords home nutrition support; nutrition; long-term care; minerals/trace elements; nutrition assessment, parenteral nutrition
Drug shortages are devastating and have plagued our patients for several years with no end in sight. During the 6-year period from January 1996 to June 2002, 224 individual drug shortages were reported nationally.1 In stark contrast, more than 200 active drug shortages were reported nationally in each year between 2010 and 2013, and there were over 300 active drug shortages present in each of quarter 1 and quarter 2 of 2014 alone.2 These shortages have adversely affected patient care; for example, the 2011 cytarabine shortage caused a rationing of the drug, with doctors having to decide which patients needed it most urgently and other patients receiving delayed treatment or less effective therapies.3,4 Major national shortages of vitamin and trace element products for parenteral nutrition (PN) formulations have occurred in the late 1980s, the late 1990s, and most recently have been ongoing since 2009; in addition, all PN components have been in short supply for the past 5 years.5,6 The current national intravenous (IV) trace mineral shortage has resulted in a variety of adverse outcomes: 20%–−25% of respondents in a 2013 survey by the Institute for Safe Medication Practices (ISMP) and 41% of respondents in a 2014 survey by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) reported suboptimal outcomes associated with the PN component shortages.6,7 In 2013, a 62-year-old PN-dependent woman had copper withheld from her PN due to a national shortage and developed copper deficiency and resultant symptomatic anemia and leukopenia.8 In 2012, 3 premature infants in Washington, DC, who received PN without zinc developed zinc deficiency with dermatitis.9 In 2013, 4 infants in Houston, Texas, receiving PN without zinc developed zinc deficiency; 3 manifested characteristic dermatitis, and the fourth died with liver failure and sepsis with an unclear role of zinc in mortality.10 Most recently, a 2014
case report described zinc and copper deficiency due to a nationwide shortage that resulted in impaired wound healing.11 Another 2014 case report described zinc deficiency in an adult surgical patient due to the nationwide shortage but did not describe any specific significant complications.12 Similarly, a 2012 case report described asymptomatic severe selenium deficiency in 5 pediatric patients receiving PN without selenium.13 Zinc is an essential trace element that is ubiquitous in Western diets. Deficiency of this element is typically seen in the context of either congenital malabsorption, such as in acrodermatitis enteropathica, increased losses, or inadequate intake. Symptoms of zinc deficiency include cutaneous manifestations of acral and perioral dermatitis, erosions and parakeratosis, alopecia, diarrhea, and decreased cellular immunity.14 In 1976, prior to routine inclusion of trace elements in PN, Kay et al15 published one of the first case series of zinc deficiency From the 1College of Physicians and Surgeons, Columbia University, New York, New York; 2Department of Surgery, Columbia University Medical Center, New York, New York; and 3Department of Medicine, Columbia University Medical Center, New York, New York. Financial disclosure: None declared. Received for publication September 4, 2014; accepted for publication October 17, 2014. Corresponding Author: David S. Seres, MD, ScM, Associate Professor of Medicine in the Institute of Human Nutrition Columbia University College of Physicians and Surgeons; Director, Medical Nutrition and Nutrition Support Service Department of Medicine, Division of Preventive Medicine and Nutrition Columbia University Medical Center P&S 9-501, 630 West 168th St, New York, NY 10032, USA. Email: [email protected]
Downloaded from pen.sagepub.com by guest on November 15, 2015
2
Journal of Parenteral and Enteral Nutrition XX(X)
in patients receiving PN, also noting that symptoms were responsive to addition of zinc. A similar study by Okada et al16 in 1976 further described the cutaneous manifestations of zinc deficiency in PN-dependent patients, as described above. By 1979, the Nutrition Advisory Group of the American Medical Association recommended the routine addition of the trace elements zinc, copper, chromium, and manganese to PN.17,18 This case report demonstrates a zinc deficiency with significant cutaneous manifestations in a PN-dependent adult patient due to a national trace mineral shortage.
Case Presentation A 52-year-old African American man with an extensive history of abdominal surgeries and persistent enterocutaneous fistula (ECF) received PN for several months without trace elements due to a national shortage. He presented to our hospital for skin graft surgery and was noted to have a diffuse painful rash. The patient had sustained an abdominal gunshot wound 30 years prior and underwent right colectomy and cholecystectomy, complicated by multiple episodes of small bowel obstruction. For one such episode 2 years prior to admission, he underwent an exploratory laparotomy with resection of a segment of proximal jejunum, complicated by persistent ECF. Postoperatively, the volume of output from the fistula remained low with a combination of tube feeds distal to the fistula and PN. After 7 months, the output from the fistula increased significantly. A fistula takedown was performed, with resection of a small segment of small bowel, but the postoperative course was complicated by recurrence of the fistula while he was eating a regular diet. Oral intake was disallowed and PN restarted. The patient was discharged to a skilled nursing facility and maintained on this regimen for the 5 months prior to the most recent admission. During these intervening 5 months, trace elements were not provided in the patient’s PN due to a national shortage. After approximately 2 months, the patient developed a persistent pruritic and painful rash over his face, trunk, and extremities. The patient had no additional significant medical or surgical history. He had no known drug allergies and was taking only hydromorphone and gabapentin for chronic abdominal pain, both upon admission and during the preceding months when the rash developed. Social history was significant only for a distant 6-pack-year smoking history. A skin graft for an abdominal wall defect near the ECF was performed and the patient was subsequently admitted. At this time, the patient’s physical examination was notable for a diffuse desquamative rash. Desquamation and hyperpigmentation were observed across his entire body but were particularly prominent on his hands, feet, elbows, and shins (Figure 1). Relevant laboratory values were as follows: white blood cells, 6.3 × 109 cells/L (3.5–9.1 × 109 cells/L); total protein, 7.4 g/dL (6.7–8.6 g/dL); serum albumin, 3.0 g/dL (3.5–5.5 g/dL); alkaline phosphatase, 27 U/L (33–96 U/L); antinuclear
Figure 1. Clockwise from left: desquamative lesions on extensor surface of arm, hand, and foot consistent with zinc deficiency dermatitis.
antibody negative, and a lipid panel with cholesterol of 99 mg/ dL (
research-article2015
PENXXX10.1177/0148607114566465Journal of Parenteral and Enteral NutritionSant et al
Case Report
Zinc Deficiency With Dermatitis in a Parenteral Nutrition–Dependent Patient Due to National Shortage of Trace Minerals
Journal of Parenteral and Enteral Nutrition Volume XX Number X Month 201X 1–4 © 2015 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0148607114566465 jpen.sagepub.com hosted at online.sagepub.com
Vivek R. Sant, BA1; Tracey D. Arnell, MD2; and David S. Seres, MD, ScM3
Abstract The shortages of intravenous drugs remains critical, with sterile injectables accounting for 80% of the approximately 300 shortages. The impact is being felt in patients dependent on parenteral nutrition (PN), and severe deficiencies are becoming more commonplace. We report here a man who developed severe zinc deficiency, manifesting as a painful desquamative rash, due to an inability to obtain multi–trace element additives for his PN. (JPEN J Parenter Enteral Nutr. XXXX;xx:xx-xx)
Keywords home nutrition support; nutrition; long-term care; minerals/trace elements; nutrition assessment, parenteral nutrition
Drug shortages are devastating and have plagued our patients for several years with no end in sight. During the 6-year period from January 1996 to June 2002, 224 individual drug shortages were reported nationally.1 In stark contrast, more than 200 active drug shortages were reported nationally in each year between 2010 and 2013, and there were over 300 active drug shortages present in each of quarter 1 and quarter 2 of 2014 alone.2 These shortages have adversely affected patient care; for example, the 2011 cytarabine shortage caused a rationing of the drug, with doctors having to decide which patients needed it most urgently and other patients receiving delayed treatment or less effective therapies.3,4 Major national shortages of vitamin and trace element products for parenteral nutrition (PN) formulations have occurred in the late 1980s, the late 1990s, and most recently have been ongoing since 2009; in addition, all PN components have been in short supply for the past 5 years.5,6 The current national intravenous (IV) trace mineral shortage has resulted in a variety of adverse outcomes: 20%–−25% of respondents in a 2013 survey by the Institute for Safe Medication Practices (ISMP) and 41% of respondents in a 2014 survey by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) reported suboptimal outcomes associated with the PN component shortages.6,7 In 2013, a 62-year-old PN-dependent woman had copper withheld from her PN due to a national shortage and developed copper deficiency and resultant symptomatic anemia and leukopenia.8 In 2012, 3 premature infants in Washington, DC, who received PN without zinc developed zinc deficiency with dermatitis.9 In 2013, 4 infants in Houston, Texas, receiving PN without zinc developed zinc deficiency; 3 manifested characteristic dermatitis, and the fourth died with liver failure and sepsis with an unclear role of zinc in mortality.10 Most recently, a 2014
case report described zinc and copper deficiency due to a nationwide shortage that resulted in impaired wound healing.11 Another 2014 case report described zinc deficiency in an adult surgical patient due to the nationwide shortage but did not describe any specific significant complications.12 Similarly, a 2012 case report described asymptomatic severe selenium deficiency in 5 pediatric patients receiving PN without selenium.13 Zinc is an essential trace element that is ubiquitous in Western diets. Deficiency of this element is typically seen in the context of either congenital malabsorption, such as in acrodermatitis enteropathica, increased losses, or inadequate intake. Symptoms of zinc deficiency include cutaneous manifestations of acral and perioral dermatitis, erosions and parakeratosis, alopecia, diarrhea, and decreased cellular immunity.14 In 1976, prior to routine inclusion of trace elements in PN, Kay et al15 published one of the first case series of zinc deficiency From the 1College of Physicians and Surgeons, Columbia University, New York, New York; 2Department of Surgery, Columbia University Medical Center, New York, New York; and 3Department of Medicine, Columbia University Medical Center, New York, New York. Financial disclosure: None declared. Received for publication September 4, 2014; accepted for publication October 17, 2014. Corresponding Author: David S. Seres, MD, ScM, Associate Professor of Medicine in the Institute of Human Nutrition Columbia University College of Physicians and Surgeons; Director, Medical Nutrition and Nutrition Support Service Department of Medicine, Division of Preventive Medicine and Nutrition Columbia University Medical Center P&S 9-501, 630 West 168th St, New York, NY 10032, USA. Email: [email protected]
Downloaded from pen.sagepub.com by guest on November 15, 2015
2
Journal of Parenteral and Enteral Nutrition XX(X)
in patients receiving PN, also noting that symptoms were responsive to addition of zinc. A similar study by Okada et al16 in 1976 further described the cutaneous manifestations of zinc deficiency in PN-dependent patients, as described above. By 1979, the Nutrition Advisory Group of the American Medical Association recommended the routine addition of the trace elements zinc, copper, chromium, and manganese to PN.17,18 This case report demonstrates a zinc deficiency with significant cutaneous manifestations in a PN-dependent adult patient due to a national trace mineral shortage.
Case Presentation A 52-year-old African American man with an extensive history of abdominal surgeries and persistent enterocutaneous fistula (ECF) received PN for several months without trace elements due to a national shortage. He presented to our hospital for skin graft surgery and was noted to have a diffuse painful rash. The patient had sustained an abdominal gunshot wound 30 years prior and underwent right colectomy and cholecystectomy, complicated by multiple episodes of small bowel obstruction. For one such episode 2 years prior to admission, he underwent an exploratory laparotomy with resection of a segment of proximal jejunum, complicated by persistent ECF. Postoperatively, the volume of output from the fistula remained low with a combination of tube feeds distal to the fistula and PN. After 7 months, the output from the fistula increased significantly. A fistula takedown was performed, with resection of a small segment of small bowel, but the postoperative course was complicated by recurrence of the fistula while he was eating a regular diet. Oral intake was disallowed and PN restarted. The patient was discharged to a skilled nursing facility and maintained on this regimen for the 5 months prior to the most recent admission. During these intervening 5 months, trace elements were not provided in the patient’s PN due to a national shortage. After approximately 2 months, the patient developed a persistent pruritic and painful rash over his face, trunk, and extremities. The patient had no additional significant medical or surgical history. He had no known drug allergies and was taking only hydromorphone and gabapentin for chronic abdominal pain, both upon admission and during the preceding months when the rash developed. Social history was significant only for a distant 6-pack-year smoking history. A skin graft for an abdominal wall defect near the ECF was performed and the patient was subsequently admitted. At this time, the patient’s physical examination was notable for a diffuse desquamative rash. Desquamation and hyperpigmentation were observed across his entire body but were particularly prominent on his hands, feet, elbows, and shins (Figure 1). Relevant laboratory values were as follows: white blood cells, 6.3 × 109 cells/L (3.5–9.1 × 109 cells/L); total protein, 7.4 g/dL (6.7–8.6 g/dL); serum albumin, 3.0 g/dL (3.5–5.5 g/dL); alkaline phosphatase, 27 U/L (33–96 U/L); antinuclear
Figure 1. Clockwise from left: desquamative lesions on extensor surface of arm, hand, and foot consistent with zinc deficiency dermatitis.
antibody negative, and a lipid panel with cholesterol of 99 mg/ dL (
