A 44-year-old homeless man presents to the emergency department after being stabbed multiple times in the abdomen. The patient is intoxicated and is unable to offer further history. His temperature is 97.5°F (36.4°C), blood pressure is 92/52 mmHg, pulse is 145/min, respirations are 33/min, and oxygen saturation is 90% on room air. He is intubated to protect his airway, given 2 units of packed red blood cells, and sent to the operating room for an exploratory laparotomy. The patient is subsequently admitted to the intensive care unit. He is extubated the next day and appears well. His vitals are within normal limits. Physical exam reveals sparse hair that is falling out throughout the patient’s body. He has a rash by the corners of his mouth. The patient has multiple loose bowel movements and on day 6 the patient’s surgical wound does not appear to be healing. It is held together only by the sutures with minimal underlying healing. Which of the following is most likely deficient in this patient?
Thiamine
Vitamin C
Zinc
Riboflavin
Zinc
This homeless patient who likely has poor nutritional status presents with angular cheilitis, sparse hair that is falling out, diarrhea, and poor wound healing, all of which are suggestive of zinc deficiency.

Zinc is involved in many physiologic processes and is an important mineral to include in the diet. Zinc deficiency is common in patients with poor nutritional status such as the homeless, individuals living in developing nations without access to food, and patients with eating disorders. Many malabsorptive conditions can cause zinc deficiency including steatorrhea and chronic pancreatitis. Zinc deficiency presents with impaired wound healing and impaired immune function. Other symptoms suggestive of zinc deficiency include xerosis, alopecia, stomatitis, oral ulceration, angular cheilitis, impaired vision (night blindness), impaired smell/taste, diarrhea, and anorexia. The treatment of zinc deficiency involves zinc supplementation and workup for any other nutritional deficiencies.

Nagata etc al. study the incidence of zinc deficiency among younger patients with anorexia nervosa. The authors find that men and women are both equally likely to have zinc deficiency when admitted. The authors recommend screening all patients with eating disorders for zinc deficiency.

Incorrect Answers:
Answer A: Riboflavin deficiency may present with angular cheilitis, stomatitis, and a non-specific rash. The treatment involves supplementing or consuming foods with riboflavin; however, it is rare in the developed world to be riboflavin deficient (due to fortified foods) and would not cause such significant wound healing issues as in this patient.

Answer B: Thiamine deficiency is common in alcoholics and can cause Wernicke-Korsakoff syndrome, which presents with ataxia, nystagmus, and ophthalmoplegia in addition to amnesia. The treatment involves the administration of high-dose thiamine.

Answer C: Vitamin C deficiency causes scurvy, which presents with easy fractures, bleeding gums or loose teeth, delayed wound healing, and perifollicular hemorrhages. It is common in the homeless and alcoholics. Treatment involves vitamin C replacement or a diet rich in fruits and vegetables.

Answer D: Vitamin D deficiency is common in the homeless, alcoholics, or those who suffer from steatorrhea (such as chronic pancreatitis or Crohn disease). It presents with weak, soft bones (osteomalacia/osteoporosis), and hypocalcemia which may present with paresthesias and tetany. Treatment involves replacement of vitamin D.

Bullet Summary:
Zinc deficiency presents with poor wound healing, hair loss, infertility, diarrhea, anorexia, and impaired immune function.