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June 1, 2008

Erosive Dermatitis and Progressive Neurological Symptoms—Quiz Case

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Arch Dermatol. 2008;144(6):795-800. doi:10.1001/archderm.144.6.795-b

A 57-year-old woman presented with a 9-month history of painful, erosive plaques in the groin, extremities, and perioral regions, which spontaneously remitted and recurred. Her review of systems was positive for glossodynia, a weight loss of 40 lb (18 kg), and an 18-month history of progressive neurological deterioration, including decreased cognition, deterioration of speech and writing, ataxia, and bowel and bladder incontinence. Physical examination revealed confluent, erythematous, eroded, scaly plaques periorally and in the groin, extending onto the upper thighs and abdomen (Figure 1), and a mild glossitis. Laboratory test results showed a decreased hemoglobin level (10.6 g/dL [reference range, 14-17 g/dL] [to convert to grams per liter, multiply by 10]), low serum zinc level (30.1 μg/dL [reference range, 60.0-120.0 μg/dL] [to convert to micromoles per liter, multiply by 0.153]), and an elevated serum glucagon level (314 pg/mL [reference range, 46-166 pg/mL] [to convert to nanograms per liter, multiply by 1.0]). Punch biopsy specimens from the left upper extremity for microscopic examination were obtained (Figure 2), and direct immunofluorescence was performed. A computed tomographic scan of the abdomen and pelvis is shown in Figure 3.

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