(BMJ)—A 6-mo girl born at 32wk of gestation presented w/ a rash, irritability, and poor weight gain x2mo. She had hx of intrauterine growth restriction due to placental insufficiency and was exclusively breastfed. A recent course of mild topical corticosteroid failed to improve the rash. Exam: scaly, red plaques around eyes, nose, mouth, and ears. What is the dx?
Atopic dermatitis
Impetigo
Acrodermatitis enteropathica
Zinc deficiency
Langerhans cell histiocytosis
You are correct. Acquired zinc deficiency was confirmed by serum zinc level in baby, mother, and breast milk. In an infant, s/sx of zinc deficiency include faltering weight, irritability, and periorificial dermatitis. This commonly occurs as a result of poor nutrition in the breastfeeding mother and the increased demand for zinc in the premature baby. Acrodermatitis enteropathica is a genetic cause of zinc deficiency that presents after the child is weaned from breast milk to formula. Both mother and child were supplemented w/ zinc sulfate x12wk while breastfeeding continued, and the baby was weaned to solids. The rash disappeared after a week and did not recur.

BMJ 2017;358:j3606

(BMJ)—On arrival to the U.K., a 2-yo girl from Brazil presented w/ a 1-day hx of a painful, itchy nodule on the sole of her R foot. After 7 days, it had grown and become more tender. Exam: 7x7-mm nodule w/ central black punctum. What is the dx?
Plantar verruca
Dermatobia hominis
Tungiasis
Fire ant bite
Cutaneous larva migrans
You are correct. Tungiasis, due to infection w/ a female Tunga penetrans, is endemic in South America and common in Brazil. This cutaneous ectoparasite is also known as a jigger, nigua, chica, pico, pique, or suthi flea. A black punctum in the center of the nodular lesion is classical of tungiasis. Following a blood meal, the female flea penetrates the skin, usually in the dorsum of the foot, under the toenail or between the toes. The burrowed flea swells in size during gestation and causes intense inflammation, erythema, pain, edema, and itching. Tx is by surgical excision. This pt had excision of the lesion, and Tunga penetrans ova were identified in the excised tissue, but the body of the flea had degenerated.

BMJ 2017;357:j2396