Patient: M.E. (55 y/o male) Chief complaint: – Painful erythematous swelling on the face.
CASE PRESENTATION Mary Palomaki May 19, 2010. Chief Complaint 16 month male with orange skin.
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Transcript of CASE PRESENTATION Mary Palomaki May 19, 2010. Chief Complaint 16 month male with orange skin.
History of Present Illness• Orange skin x 3 weeks• Tugging on right ear• Fever x 2 days, Tmax 102 PR• Denies: change in activity, cough, runny nose,
rash, vomit, diarrhea, travel, sick contacts• Normal PO• Normal Stool
– Normal in color, consistency
• Normal UOP– Normal color
Past Medical History
• Developmental Delay
• Delayed Motor: Sit with support, no crawling, no walking
• Delayed Speech: no words
Physical Exam
• VS: T: 101.3 HR: 120 RR 30 • O2Sat 100% RA• Gen: awake, alert• HEENT: NC, Perrl, EOMI, anicteric, mmm,
oropharynx: no lesion, no erythema, R TM: + erythema, +bulging, L TM: dull
• CV: S1, S2, no murmur
Physical Exam 2
• Resp: b/l clear to ausculatation• ABD: BS+, soft, no distention, no HSM• Ext: FROM x 4, cap refill <2s• SKIN: orange/yellow tinged body, extremities,
>>pigmentation palms, soles• GU: b/l descended testicles, normal phallus • Neuro: mild decreased tone, 2+ reflexes
Differential Diagnosis
• Jaundice• Carotenemia• Excess ingestion/percutaneous absorption of
chemicals– Quinacrine– Mepacrine– Dinitrophenol– Saffron– Tetryl– Picric acid
• Inborn errors of metabolism
Carotenemia
• Increased number of carotinoids in the epidermis
• Carotinoids are plant pigments– Act as antioxidants– Cell growth– Immune function
• Carotene is hydrocarbon part of the carotinoid
• Carotene from plants is primary dietary source of vitamin A
Foods Rich in Carotene
• Asparagus, broccoli, carrots, cucumbers, lettuce, spinach, squash, sweet potatoes, apples, oranges, peaches, prunes, tomatoes, yams, butter, egg yolk, milk, yellow corn
• Baby foods and pureed foods allow greater absorption of carotene– Cell wall is broken during puree process,
releasing carotene
Carotene Metabolism
Plant Cell
Carotene
In mucosal cells:
B-carotene-->2 molecules retinol (Vitamin A metabolite)
B-carotene 15, 15’dioxygenase
Excretion via colon, epidermis
Carotene
• Accumulates in areas of concentrated sweat glands– Palms– Soles– Nasolabial folds
• Is present in high concentration in breast milk
Carotenemia
• Mostly dietary• Associated with
– Hypothyroidism– Diabetes Mellitus– Liver disease– Kidney disease– Anorexia Nervosa
• Familial– Decrease amount of B-carotene 15,
15’dioxygenase
Diabetes Mellitus
• Most diabetics have elevated serum concentrations of B-carotene
• Only 10% show skin color changes
• Some diabetics have impaired conversion of B-carotene to retinol
Hypothyroidism
• Decreased conversion of carotene to Vitamin A
• Hyperlipidemia and hypercholesterolemia exacerbate this effect
Anorexia Nervosa
• Altered lipid metabolism increases cholesterol levels, decreasing metabolism of carotene
Carotene Absorption
• Determined by type of food– Pureed foods
• Manifest on skin 2 weeks after elevated serum levels of carotene
Complications
• None
• Serum levels greater than three times the upper limit of normal do not cause hypervitaminosis A– Conversion of carotene to Vitamin A is
slow
Vitamin A Deficiency
• Photophobia
• Xerophthalmia
• Keratomalacia
• Epiphyseal bone formation
• Defective tooth enamel
• Retarded growth
Riboflavin (B2) deficiency
• Burning, itching of eyes
• Corneal vascularization
• Poor growth
• “Ariboflavinosis”
• Phototherapy breaks down riboflavin– Careful with treatment of neonatal jaundice
Lycopenemia
• Lycopene found in tomatoes, beets, chili peppers
• Turns skin reddish color, with excessive ingestion
• Harmless condition
• Resolves without treatment
Risk B6 deficiency
• Oral contraceptives
• Isoniazid
• Penicillamine
• Corticosteroids
• Anticonvulsants
• dialysis
Rickets
• FTT• Protruding abdomen• Muscle weakness• Fractures• Craniotabes• Frontal bossing• Craniosynostosis• Harrison groove• Scoliosis• Valgus/varus deformities
• Windswept deformity
• Leg pain• Hypocalcemic
symptoms:– Tetany– Seizures– Stridor from
laryngospasm
References
• Pitette, RD. Carotenemia. Web. Emedicine.com 16 June 06.
• Nelson’s Textbook of Pediatrics. Ch 49.• Tyler, I, Wiseman MC, Crawford TR. Cutaneous
manifestations of eating disorders. J Cutan Med Surg 2002 6(4): 345-53
• Karthik, SV et al. Carotenemia in infancy and its association with prevalent feeding practices. Pediatric Dermatology 2006;23:571-573