University of Miami, Jackson Memorial Hospital Fort Lauderdale, FL, United States
Jonathan L. Steinberg, MD, MA1, Smriti R. Kumar, MD, EdM2, Laura Aponte-Becerra, MD2, Maya Gabel, MD2 1University of Miami, Jackson Memorial Hospital, Fort Lauderdale, FL; 2University of Miami, Jackson Memorial Hospital, Miami, FL
Introduction: Malnutrition is a common diagnosis with a broad differential and etiology-specific therapies are available if the cause is identified. We present an unusual case of severe protein-calorie-vitamin malnutrition related to poor oral intake and Scabies-induced erythroderma with exfoliative protein wasting complicated by thiamine deficiency and Wet Beriberi.
Case Description/Methods: An 80-year-old male with a history of Type 2 diabetes, COPD, and prostate cancer treated in 2010 who had been living in rural Guatemala for the past twelve years was admitted with severe muscle weakness. On evaluation he was found to have anasarca, tachycardia, isolated proximal muscle quadriparesis, atrophic glossitis, and diffuse erythroderma. Initial testing was equivocal, with results notable for mild leukocytosis with eosinophilia, negative infectious and malignancy work up, type-II NSTEMI with moderate right ventricular overload, and pre-renal acute kidney injury.
The initial clinical picture was consistent with severe protein-calorie malnutrition from multiple causes, including poor oral intake, chronic disease, and erythroderma-induced exfoliative protein wasting. He was also found to have thiamine deficiency (< 6 nmol/L, normal 8-30) with evidence of circulatory overload and symmetric motor/sensory peripheral neuropathy consistent with a diagnosis of Wet Beriberi. Furthermore, a biopsy of his erythroderma revealed Norwegian crusted scabies, which was treated with ivermectin and permethrin. Nearly all the patient’s symptoms, including his anasarca, tachycardia, erythroderma, mixed peripheral neuropathy, and muscle weakness, resolved with aggressive nutrition and vitamin supplementation.
Discussion: Protein-calorie malnutrition is very common and many acute and chronic conditions often contribute. However, erythroderma is a very rare condition with an annual incidence of approximately 1 per 100,000 adults, and even more rarely exhibits such widespread exfoliative protein loss to result in malnutrition. Treatment targets the underlying cause, which includes inflammatory dermatoses, infections, malignancies, and drugs. Thiamine deficiency severe enough to cause Wet Beriberi is also rare in adults and is far more likely to occur in developing countries and rural areas. This case illustrates both the importance of having a broad differential for malnutrition and a high index of suspicion for complications, as both the rare cause and rare complication seen in this case were effectively treated with targeted therapy.
Figure: Image 1: A) Widespread erythroderma with visible excoriations covering >50% of the body surface area; B) Erythroderma and excoriations on the foot, with an area of clustered crusting representing a high number of scabies mites
Jonathan Steinberg indicated no relevant financial relationships.
Smriti Kumar indicated no relevant financial relationships.
Laura Aponte-Becerra indicated no relevant financial relationships.
Maya Gabel indicated no relevant financial relationships.
Jonathan L. Steinberg, MD, MA1, Smriti R. Kumar, MD, EdM2, Laura Aponte-Becerra, MD2, Maya Gabel, MD2. P2014 - Severe Protein-Calorie-Vitamin Malnutrition Caused by Overlapping Scabies-Induced Erythroderma, Thiamine Deficiency and Wet Beriberi, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.