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Comments, Opinions, and Brief Case Reports
November 11, 2002

Zinc Deficiency Leading to Intractable Vomiting

Arch Intern Med. 2002;162(20):2376-2377. doi:10.1001/archinte.162.20.2376

Zinc deficiency is an unusual complication of total parenteral nutrition (TPN).1 We report a case of a young woman with zinc deficiency caused by prolonged parenteral nutrition whose chief initial presentation was intractable vomiting.

A white, 21-year-old woman was admitted in December 1997 with persistent vomiting. In August 1997, the patient experienced penetrating thoracic and abdominal injuries caused by 2 gun shots. At another hospital, she was submitted to a surgical procedure to repair a right ventricle lesion and a transverse colon injury and to establish a colostomy. In the postoperative follow-up, she developed mediastinitis, recurrent peritonitis, and prolonged paralytic ileus. During the next 3 months, the patient received TPN. Four months after surgery, she was discharged, and 5 days later, persistent vomiting (5-7 episodes a day), intermittent diarrhea, and disorientation had begun. One week later she was referred to our hospital. Findings from initial examination showed no abnormalities except for amnesia and temporospatial disorientation. Results of routine biochemistry and hematology tests were normal except for a low alkaline phosphatase activity (65 IU/L [normal, 80-130 IU/L]). Stool cultures and parasitologic analysis findings were negative. During the following 2 weeks, vomiting increased in frequency (up to 12 episodes a day), and she was unresponsive to treatment with metoclopramide, promethazine, diazepam, and ondansetron. An upper gastrointestinal tract series, an esophagogastroduodenoscopy, and an abdominal ultrasound were performed and revealed no abnormalities. A cranial computed tomographic scan and cerebrospinal fluid analysis results were also normal. Four weeks after the beginning of symptoms, alopecia, perioral ulcers (Figure 1, A), and periungual lesions (Figure 1, B) were noted. A clinical hypothesis of zinc deficiency was made. A serum zinc level of 63 µg/dL (9.6 µmol/L) was found (low, <70 µg/dL [<10.7 µmol/L]).2 We then assessed the patient files at the former hospital and disclosed that TPN solutions had adequate vitamin supplementation but no trace elements. Because there had been adequate vitamin supplementation during TPN therapy and there was no clinical picture of other trace element deficiency, exclusive parenteral reposition of zinc was promptly instituted. Two days later, vomiting as well as diarrhea disappeared, serum alkaline phosphatase returned to normal levels, and a striking improvement of dermatitis and mental alterations were observed, confirming the diagnosis of zinc deficiency. Five days later she was discharged and used oral zinc supplementation for 2 months. When last seen in May 2001, she was asymptomatic.

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