University of Florida Shands Hospital Gainesville, FL
Introduction: Micronutrient deficiencies occur in patients with bariatric surgery due to disruption of normal absorption and anomaly of the gut anatomy. Patients with bariatric surgery were found to be deficient in B1, B9, B12, Copper, and Iron. Inadequate repletion of these deficiencies can lead to multi-system impairments. The clinical findings of micronutrient deficiencies may mimic other disease presentations such as those of autoimmune etiologies. The purpose of this case is to promote a high suspicion of micronutrient deficiencies in patients with bariatric surgery with specific clinical and laboratory findings.
Case Description/Methods: This is a 50-year-old severely malnourished female with a past medical history significant for gastric bypass in 2011 who presented with generalized weakness and diffuse desquamating rash. The patient had nausea, vomiting, diarrhea, leukopenia, and anemia with unintentional weight loss of 13.6 kg for 4 weeks prior to presentation. Dermatology and Nutrition were consulted. Autoimmune workup was initiated, which came back negative. Dermatology concluded the rash was due to nutritional deficiency and requested skin biopsy and micronutrient levels. Labs showed low levels of the following Vitamins: A, B1, B6, C, and E, along with Zinc and Copper (Table 1). She was also determined to be severely malnutrition due to her weight loss, low BMI, Prealbumin, Albumin, and total protein (Table 1). Skin biopsy was compatible with nutritional deficiency. Once it was determined that the patient’s clinical manifestations were due to nutritional deficiency, intravenous micronutrients were administered for 2 weeks (Table 1). As a result of the supplementation, there was a tremendous improvement in her weight, strength, gait, diarrhea, ability to tolerate oral intake, skin lesions, leukopenia, and anemia (Image 1). The patient was transferred to the floor, however, later developed acute respiratory failure and subsequent cardiac arrest.
Discussion: All in all, short-term benefits of bariatric surgery may result in weight reduction, however, severe malnutrition can develop over a prolonged period eventually leading to systemic clinical deterioration. Additionally, clinical manifestations of nutritional deficiency may present like other diseases obscuring the need to consider micronutrient deficiencies as the primary cause. Clinicians should have a high suspicion of nutritional deficiency in the setting of a history of bariatric surgery and replete deficiencies to optimize clinical outcomes.
