Jerkins, James

Juhasz, Margit

Laquer, Vivian

Smith, Janellen

English

eScholarship - University of California

UC IrvineUC Irvine Previously Published WorksTitle“Peeling paint” dermatosis in a leukemia patientPermalinkhttps://escholarship.org/uc/item/7xn6d98zJournalJAAD Case Reports, 6(4)ISSN2352-5126AuthorsJuhasz, MargitLaquer, VivianJerkins, Jameset al.Publication Date2020-04-01DOI10.1016/j.jdcr.2020.02.005 Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaCASE REPORTFrom theIrvinea;of MedFunding sConflicts oCorresponDermatIrvine,354‘‘Peeling paint’’ dermatosis in aleukemia patientMargit Juhasz, MD,a Vivian Laquer, MD,a James Jerkins, MD,b and Janellen Smith, MDaIrvine, California, and Milwaukee, WisconsinKey words: cancer; kwashiorkor; peeling paint dermatosis; protein malnutrition.INTRODUCTIONKwashiorkor refers to signs and symptoms result-ing from severe protein malnutrition. Loss of dietaryprotein causes osmotic imbalance and fluid reten-tion, with the characteristic protuberant abdomenand dependent edema. Lack of protein results inhypoalbuminemia, growth retardation, mentalapathy, immunodeficiency, hepatic steatosis, ane-mia, and cutaneous findings such as pigmentarychanges (eg, darkening of the skin, alternating bandsof normal colored and lighter hair ‘‘flag sign’’),alopecia, and dermatoses, including the pathogno-monic ‘‘peeling paint.’’1Kwashiorkor often affects populations of the un-derdeveloped world, with higher incidences in areasof famine. Although there are few data on kwashior-kor’s incidence in theUnited States, a 2011-2012 reportfrom the Centers for Disease Control and Preventiondescribes the prevalence of underweight adults (bodymass index\18.5) to be 0.9% of individuals aged 40 to59 years and 1.6% of those aged 60 years and older.2Because access to nutrition is not usually a factor inmalnutrition development in the United States, under-lying causes such as eating disorders, fad diets, dietaryrestrictions (real or ‘‘perceived’’ sensitivities), chronicdisease, and hospitalization have to be addressed.3-6We describe a rare case of ‘‘peeling paint’’ dermatosisin a leukemia patient thought to have developedkwashiorkor because of neutropenic bowel inflam-mation and dietary restriction.CASE REPORTWe present a 36-year-old woman with B-cellacute lymphoblastic leukemia treated with theDepartment of Dermatology, University of California,and Division of Hematology and Oncology, Departmenticine, Medical College of Wisconsin, Milwaukee.bources: None.f interest: None disclosed.dence to: Margit Juhasz, MD, Department ofology, University of California, Irvine, 118 Med Surg 1,CA 92697. E-mail: mjuhasz@uci.edu.CALGB-10403 protocol7 and ponatinib whose clin-ical course was complicated by chronic thrombocy-topenia requiring monthly platelet transfusion, andacute renal failure necessitating dialysis and a low-protein diet. After the patient’s renal failureimproved, dialysis was discontinued; however, shecontinued her low-protein diet for 8 months, withoutfruit or vegetables, nor oral supplementation ofvitamins, minerals, or protein. The patient presentedwith asymptomatic desquamation of the extremitiesand trunk (Fig 1), 10 of 10 abdominal pain, and 10 to12 episodes of diarrhea necessitating hospital admis-sion for further evaluation. Her physical examinationwas significant for ichthyosiform plate-like scale withminimal erythema over the trunk and large adherentsheets of peeling skin over the extremities.Skin biopsy was remarkable for epidermal pallor,as well as increased compact orthokeratosis withunderlying basket weave, which may be suggestiveof a desquamative process (Fig 2). Laboratoryassessments were notable for decreased levels ofalbumin (2.3 g/dL; range 3.7-5.3 g/dL), copper(65 g/dL; range 85-155 g/dL), vitamin A/retinol(0.07 mg/L; range 0.30-1.20 mg/L), vitamin B1(4 nmol/L; range 8-30 nmol/L), vitamin B6(8.6 nmol/L; range 20-125 nmol/L), vitamin D/25-hydroxycholecalciferol (7.5 mg/mL; range [40 ng/mL), vitamin E/a-tocopherol (5.1 mg/L; range 5.5-18.0 mg/L), and zinc (44 g/dL; range 55-150 g/dL).Folate, vitamin B2, B12, and C levels were withinnormal limits. In regard to her abdominal pain, thepatient received a diagnosis of neutropenic entero-colitis and typhlitis as a complication of herchemotherapy-induced neutropenia. The patientJAAD Case Reports 2020;6:354-6.2352-5126 2020 by the American Academy of Dermatology, Inc. Publishedby Elsevier, Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).https://doi.org/10.1016/j.jdcr.2020.02.005Fig 1. Ichthyosis and platelike scale of the ‘‘peeling paint’’ dermatosis, characteristic ofkwashiorkor of the back (A), anterior portion of the chest (B), and lower extremity (C).Fig 2. Skin biopsy with epidermal pallor and compactorthokeratosis with underlying basket weave.JAAD CASE REPORTSVOLUME 6, NUMBER 4Juhasz et al 355was also found to have an unrelated Klebsiellaurinary tract infection, requiring treatment withintravenous meropenem. The initial differentialdiagnosis of her dermatosis included a paraneo-plastic process, drug reaction, transfusion reaction,or nutritional deficiency. Given the patient’s historyof poor diet, diagnosis of neutropenic enterocolitisand typhlitis, profoundly low albumin level, and‘‘peeling paint’’ dermatosis, she received a diagnosisof kwashiorkor. Although she had numerous de-ficiencies, we believed that the overall presentationof her skin fit best with this diagnosis.The patient’s malnutrition was initially treatedby encouraging oral intake and dronabinol 2.5 mg(titrated up to 10 mg) orally twice daily.Unfortunately, albumin levels continued todecrease. It was decided to start total parenteralnutrition and her skin findings resolved. She wasdischarged from the hospital in stable conditionand has not experienced further episodes ofdesquamation.DISCUSSIONKwashiorkor is rarely diagnosed in the UnitedStates; however, chronic diseases (gastrointestinal,cardiovascular, neuromuscular, febrile, and psychi-atric diseases; malignancy; or immunodeficiencysuch as AIDS), prolonged hospitalization, or bothmay predispose patients to protein depletion.Approximately 70% of cancer patients will developJAAD CASE REPORTSAPRIL 2020356 Juhasz et almalnutrition, with low protein and albumin levels.4-6Specifically, in chronic lymphoid leukemia, produc-tion of oleoylethanolamide causes lipolysis andcontributes to cachexia.8Our patient presented with several predisposingfactors for severe protein malnutrition, includingrestrictive diet, enterocolitis, and typhlitis, causingdecreased nutritional absorption, as well as a chronicdisease course with multiple hospitalizations. Inaddition to hypoalbuminemia and ‘‘peeling paint’’dermatosis characteristic of kwashiorkor, the patienthad multiple vitamin and mineral deficienciesconsistent with poor diet. Vitamins and minerals actas important enzyme cofactors, and their dietary lossmay also result in cutaneous disease. Decreasedzinc level is implicated in skin ulceration and poorwound healing. Vitamin B3 and B6 deficienciescause pellagra and pellagra-like dermatitis, whiledecreased vitamin A causes xerotic, thickened skinwith perifollicular scale.Seemingly rare nutritional deficiencies may occurin patients who undergo massive stress such aschronic disease, prolonged hospitalization, or self-imposed dietary restrictions. Appropriate counselingof patients at risk should occur with a multidisci-plinary team including clinicians, nutritionists, anddieticians to ensure proper nutrition. With thesecomorbidities in mind, physicians should anticipatethe development of severe protein malnutrition inspecific populations, and be ready to diagnose andtreat resulting dermatoses early to avoid furtherpatient morbidity or mortality.REFERENCES1. Latham MC. The dermatosis of kwashiorkor in young children.Semin Dermatol. 1991;10(4):270-272.2. Fryar CD, Ogden CL. Prevalence of underweight among adultsaged 20 and over: United States, 1960-1962 through 2011-2012.Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/data/hestat/underweight_adult_11_12/underweight_adult_11_12.pdf; 2014. Accessed February 26, 2020.3. Rogers AS, Shaughnessy KK, Davis LS. Dermatitis anddangerous diets: a case of kwashiorkor. JAMA Dermatol. 2014;150(8):910-911.4. Waltman NL, Bergstrom N, Armstrong N, et al. Nutritionalstatus, pressure sores, and mortality in elderly patients withcancer. Oncol Nurs Forum. 1991;18(5):867-873.5. Alam M, Grossman ME, Longley BJ, et al. Kwashiorkor inpatients with AIDS. Cutis. 2001;67(4):321-324.6. Willard MD, Gilsdorf RB, Price RA. Protein-calorie malnutrition ina community hospital. JAMA. 1980;243(17):1720-1722.7. Stock W, Luger SM, Advani AS, et al. A pediatric regimen forolder adolescents and young adults with acute lymphoblasticleukemia: results of CALGB 10403. Blood. 2019;133(14):1548-1559.8. Masoodi M, Lee E, Eiden M, et al. A role for oleoylethanolamidein chronic lymphocytic leukemia. Leukemia. 2014;28(7):1381-1387.

“Peeling paint” dermatosis in a leukemia patient

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"Peeling paint" dermatosis in a leukemia patient.

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