Zinc deficiency with desquamating rash and hyperammonaemia after Roux-en-Y gastric bypass surgery

Nutritional deficiencies are common after Roux-en-Y gastric bypass (RYGB) surgery. However, severe zinc deficiency is a diagnostic challenge, given the non-specific skin findings and associated metabolic derangements. We report a case of a female in her 40s with history of RYGB complicated by nutritional deficiencies, alcoholic steatohepatitis, anastomotic ulcers and desquamating skin disorder who presented with altered mental status and haemorrhagic shock secondary to upper gastrointestinal bleed. Her laboratory studies revealed anaemia, hyperammonaemia (337 µmol/L) and elevated creatinine with previous biopsy of rash indicating spongiotic dermatitis that improved with inpatient treatment of triamcinolone, clindamycin and vitamin supplementation. Her hospital course was complicated by extended-spectrum beta-lactamase (ESBL) bacteraemia and fungal skin infection requiring several debridement operations of her thighs. Her clinical course remains evolving with recurrent hospital admissions with hyperammonaemia and persistent encephalopathy. In a patient presenting with metabolic derangements and skin rash after RYGB, zinc deficiency is an important differential diagnosis.