A case of zinc deficiency histologically showing spongiform pustules of Kogoj.

An 89-year-old Japanese woman was referred to us for evaluation of multiple scaly erythematous plaques with erosions that had developed over her entire body. She had received enteral feeding because of eating disorders for 9 months. Although she had been treated with topical steroid ointment and oral administration of prednisolone and terbinafine before admission to our department, there was no response. Due to concurrent severe diarrhoea, she was also treated with intravenous antibiotics (imipenem), but the treatment was not effective. Physical examination revealed multiple erythematous plaques with oedema, irregular in shape, on her face, especially around the eyelids, vulva, trunk and extremities (Fig. 1). The centre of each erythema was erosive, and some pustules were observed on the surface. Laboratory examinations demonstrated the following values: white blood cell count 13.2 × 109/l; C-reactive protein 6.9 mg/dl; serum zinc level 5.2 μmol/l (normal range 9.2–20 μmol/l). No fungus was found on the erythema. A biopsy specimen taken from the erythema with pustules showed hyperkeratosis, parakeratosis, acanthosis and subcorneal spongiform pustules of Kogoj (Fig. 2). Based on these findings, a diagnosis of zinc deficiency was made. Supplementation of zinc by oral administration of zinc sulphate for 2 weeks improved the skin lesions.