A 54-year-old male who underwent BPD following the Scopinaro technique in October 2000.
The patient had morbid obesity associated with multiple comorbidities such as diabetes mellitus, hypertension, dyslipidemia, acute myocardial infarction, steatohepat and obstructive sleep apnea syndrome.
Preoperative weight and body mass index (BMI) were 122 kg and 41.3 kg/m2, respectively.
During the first year after surgery, the patient had a loss of 50 kg and later weight regained 70-72 kg and BMI was 24.4 kg/m2.
In April 2008, the patient was hospitalized for presenting a clinical picture characterized by skin lesions that had started one year after the bariatric technique with progressive worsening in the last 2 years.
He had previously been treated by his primary care physician with minus oral medication without clinical improvement.
The patient also reported asthenia, muscle weakness, generalized bone pain, 6-8 daily bowel movements with steatorrhea and progressive loss of vision, especially at night.
In the interview, the patient recognized poor compliance with treatment and nutritional monitoring recommended after surgery, with poor adherence to diet and supplementation of vitamins and trace elements prescribed.
Skin examination revealed generalized xerosis along with multiple brownish follicular papules and nodules with keratin plugs.
These lesions were located in the abdomen and extension surfaces of upper and lower limbs.
No mucosal involvement was observed.
The hair was scarce, fragile and dry.
Skin biopsy revealed multifocal hyperkeratosis associated with acanthosis and hair follicles occupied by keratin plugs, which in extreme cases was accompanied by pseudocystic dilation of these follicles.
The dermis showed vascular proliferation and chronic nonspecific inflammatory changes.
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Pathological examination revealed nictalopy and the presence of xerophthalmia in both eyes characterized by diffuse conjunctival xerosis together with Bitot staining.
A superficial micropunctate xerosis and corneal xerosis were observed.
With the clinical suspicion of vitamin A deficiency and in view of the impossibility of determining the plasma levels of vitamin A in our hospital, treatment was initiated with an oral dose of 60,000 IU of vitamin A together with an intravenous solution of vitamin A soluble at 3,500 μg.
Laboratory data showed microcytic iron deficiency anemia with a hemoglobin value of 8.1 g/dl (range 13-17 g/dl) and iron value of 19 μg/dl (range 49-150 μg/dl).
Vitamin B12 and folic acid levels were normal.
Other nutritional parameters detected albumin values of 3.4 g/dl (3.4-4.8 g/dl), prealbumin 18.5 mg/dl (range 18 mg/dl), plasmatic protein linked to 110 mg/dl (2.7 mg/dl).
The patient had vitamin D levels of 9.9 ng/dl (range 11-70 ng/dl) with parathyroid hormone (PTH) values of 315 μU/ml (range 10-80 μU).
Prothrombin activity was normal.
Vitamin E and B levels could not be determined.
Treatment was completed with a low-fat normocalorie diet, high-protein enteral supplements, transfusion of other vitamins and supplementation with oral and intravenous trace elements.
The patient showed a clear progressive improvement of the dermatological lesions and of the involvement until resolution after 2 months.
She was discharged with a daily dose of 50,000 IU of vitamin A.
In May 2010, the patient required a new hospital admission due to worsening of the skin lesions, together with a severe protein conversion deficit due to surgical technique re-nutrition, due to abandonment of nutritional treatment.
Laterolateral enteroanastomosis of the biliopancreatic loop and food loop was performed, leaving the entire intestine in circulation.
Currently, the patient has an adequate nutritional status, his weight is 66.1 kg, his BMI is 23.1 kg/m2 and his skin shows residual atrophic pigmentation.
Nutritional analytical parameters were normal as well as plasma levels of vitamin A (54 μg/dl) without requiring supplementation with vitamin A.
