Picture of the Month—Diagnosis | Congenital Defects | JAMA Pediatrics | JAMA Network
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Special Feature
August 3, 2009

Picture of the Month—Diagnosis

Arch Pediatr Adolesc Med. 2009;163(8):766. doi:10.1001/archpediatrics.2009.126-b

Based on the history, clinical picture, and low alkaline phosphatase level, we considered zinc deficiency with an acrodermatitis enteropathica–like picture. This was confirmed (serum zinc level, 30.7 μg/dL [to convert to micromoles per liter, multiply by 0.153]; all measurements by atomic absorption). We started zinc supplementation with an initial bolus of zinc gluconate (10 mg/kg/d) over 3 days and subsequent maintenance therapy of 2 mg/kg/d. The bacterial superinfection was treated intravenously with amoxicillin and clavulanate potassium (skin swab positive for Staphylococcus aureus) for 10 days. The skin lesions and child's irritability improved rapidly (Figure 3) and the stools normalized within 3 days. Follow-up blood work 2 weeks later showed that the level of alkaline phosphatase, a zinc-dependent metalloenzyme, had also normalized. Further analyses revealed a very low zinc level in his mother's breast milk (17.0 μg/dL) and a normal maternal blood zinc level of 76.5 μg/dL. After discharge, the boy was weaned off breast milk. Three months later zinc supplementation was stopped after levels of zinc (84.3 μg/dL) and alkaline phosphatase (763 U/L) had been reevaluated, and another 3 months later the child was still symptom-free. The child's condition was most likely attributable to acquired zinc deficiency due to defective secretion of zinc into the maternal breast milk.