A 34 y.o. woman who is a daily meth user comes in with a rash and eye pain

she has decreased acuity in the eye

and WBCs in the anterior chamber

and a large corneal ulcer

but she also has a papular skin rash all over her body. What could be wrong?

Our patient was vitamin A deficient.

She had a duodenal switch procedure for weight loss 1/2018 when she lived in California. Over the first year she lost 200 lbs.  Then she began to have difficulty eating and continued to lose weight. She was hospitalized in 2019 in North Dakota and found to be severely malnourished.  She was unable to have the duodenal switch reversed because of COVID.

Vitamins or “vital amines”  are essential organic compounds that cannot be synthesized by humans. The condition was first described by the Egyptians who found that night blindness could be treated by consuming liver. In 1913, Vitamin A was the first fat-soluble vitamin to be discovered.    Vitamin A deficiency remains the major cause of blindness in developing countries with 30% of children under the age of 5 affected.

The clinical manifestations of Vit A deficiency are often found in the eyes and skin.  Xeropthalmia or dry eye caused by the lack of tears is the initial presentation of Vit A deficiency  with night blindness (nyctalopia) as a result. This eventually  leads to keratitis and corneal ulcers as in our patient.  Skin manifestations include dry  or thickened skin (toad skin) often over bony projections.

Vit A deficiency leads to impaired immune response because  T-killer cells require the retinol metabolite retinoic acid as a ligand for reproduction.

In addition to diet and duodenal malabsorption, pancreatic insufficiency, biliary obstruction,tropical sprue, cystic fibrosis, inflammatory bowel disease and alcoholism have been associated with Vit A deficiency.

World Health Organization Global Prevalence of Vitamin A Deficiency in Populations at Risk 1995-2005.  World Heath Organization;Geneva, Switzerland:2009 http://apps.who.int/iris/bitstream. 100665/44110/9789241598019_eng.pdf

Stevens F, Bennett J, Hennoocq Q, et al. Trands and mortality effects of vitamin A deficiency in children in 138 low-income and middle-income countries between 1991 and 2013: A pooled analysis of population-based surverys.  Lancet Glob. Health 2015;3:3528-536.

Eusterman G, Wilbur D. Clinical features of Vitamin A deficiency.  JAMA 1932;98(24):2054-60

It takes some time to become vit A deficient