Journal of Obesity & Weight Loss Therapy
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A 29-year-old man had laparoscopic biliopancreatic diversion 4 years ago for his morbid obesity. Two years after the surgery,
he started to have macular rash which is non-itching and non-blenching but later on, it progress to papular lesions. It
involved mainly extensor surface of lower and upper limbs. Few months later, many lesions developed on flexor aspect of thigh,
lower abdomen, groin and scrotum. His skin examination showed bilaterally symmetrical discrete, dry, hard, keratotic, follicular,
dark colored papules with keratinous plug localized to extensor extremities, elbows, knees, thighs and buttocks. Complete blood
count, renal and liver function were normal. Vitamin D level was 9.8 nmol/L (normal>70). Punch biopsy left thigh showed
hyperkeratosis, acanthosis, dermal edema, fibrosis and chronic inflammation with final diagnosis of bowel bypass syndrome. He
was started on vitamin D treatment and doxycycline 200 mg daily for 4 months but unfortunately no improvement of the skin
lesions was seen. Three months after stopping doxycycline, he started to have xerophthalmia and progressive night blindness lead
to inability to do an elective intubation since he is an anestheolgist. Eye examination revealed conjuctival xerosis and Bitot's spots.
Dilated fundus and examination visual acuity were normal. The revised skin biopsy report was consistent with phrynoderma. The
serum level of vitamin A was signicantly low, at <0.1 μmol per liter (normal 0.68-4.08). He was started on vitamin A therapy with
substantially improvement of his night blindness also the skin lesions started to heal slowly with little atrophy.
Nasser Al Kahtany, MBBS, AmBIM, AmBIM (Endocrine) is an endocrinologist working at Prince Sultan Military Medical City. He is also supervisor
of Endocrine Fellowship. He had his Internal Medicine and Endocrine Fellowship from University of Alberta Hospital. He has an interest in obesity
disorder and runs an obesity clinic at his institute. He is a member of Endocrine Society, Saudi Endocrine Society, American College Physicians and
Saudi Osteoporosis Society.
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