Explanation/Literature ReviewThis patient’s findings are consistent generalized pustular psorasis. This often occurs in the setting of acute withdrawal from systemic corticosteroids but can also occur from administration of certain medications such as beta blockers and lithium, which tend to exacerbate psoriasis. Studies show that only about 10% of patients have preceding history of psoriasis. Electrolyte abnormalities can occur in generalized pustular psoriasis, in particular hypocalcemia, which, if severe enough, can lead to neurologic and cardiologic abnormalities. The mechanism is thought to be related to increased vascular permeability to serum proteins such as albumin, leading to hypoalbuminemia from loss to the interstitial space and urinary excretion. As around 40 percent of serum calcium is bound to these proteins, hypoalbuminemia results in hypocalcemia. Other cationic minerals such as zinc are also protein-bound, and as such patients may also develop hypozincemia. Consumption of zinc from rapid cell proliferation and turnover in psoriatic lesions may also contribute to the hypozincemia.Autoimmune thyroiditis and type 1 diabetes mellitus can be sequelae of DRESS syndrome and are usually seen several months after resolution of the acute phase of the disease. These are not typically complications of pustular psoriasis.The correct answer is B: HypocalcemiaReferences1. Creamer D, Allen M, Jaggar R, Stevens R, Bicknell R, Barker J. Mediation of systemic vascular hyperpermeability in severe psoriasis by circulating vascular endothelial growth factor. Arch Dermatol. 2002 Jun;138(6):791-6.2. Ala S, Shokrzadeh M, Golpour M, Salehifar E, Alami M, Ahmadi A. Zinc and copper levels in Iranian patients with psoriasis: a case control study. Biol Trace Elem Res. 2013 Jun;153(1-3):22-7.3. Wallace HJ. Generalized pustular psoriasis (Von Zumbush) with episodic hypocalcemia. Proc R Soc Med. 1965 Jun;58:425-7.Senior Resident Peer-to-Peer Case Studies
June 2017 | Volume 16 | Issue 6 | Features | 628 | Copyright © June 2017
Thomas Lee MD, Julia Schwartz MD
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Explanation/Literature ReviewThis patient’s findings are consistent generalized pustular psorasis. This often occurs in the setting of acute withdrawal from systemic corticosteroids but can also occur from administration of certain medications such as beta blockers and lithium, which tend to exacerbate psoriasis. Studies show that only about 10% of patients have preceding history of psoriasis. Electrolyte abnormalities can occur in generalized pustular psoriasis, in particular hypocalcemia, which, if severe enough, can lead to neurologic and cardiologic abnormalities. The mechanism is thought to be related to increased vascular permeability to serum proteins such as albumin, leading to hypoalbuminemia from loss to the interstitial space and urinary excretion. As around 40 percent of serum calcium is bound to these proteins, hypoalbuminemia results in hypocalcemia. Other cationic minerals such as zinc are also protein-bound, and as such patients may also develop hypozincemia. Consumption of zinc from rapid cell proliferation and turnover in psoriatic lesions may also contribute to the hypozincemia.Autoimmune thyroiditis and type 1 diabetes mellitus can be sequelae of DRESS syndrome and are usually seen several months after resolution of the acute phase of the disease. These are not typically complications of pustular psoriasis.The correct answer is B: HypocalcemiaReferences1. Creamer D, Allen M, Jaggar R, Stevens R, Bicknell R, Barker J. Mediation of systemic vascular hyperpermeability in severe psoriasis by circulating vascular endothelial growth factor. Arch Dermatol. 2002 Jun;138(6):791-6.2. Ala S, Shokrzadeh M, Golpour M, Salehifar E, Alami M, Ahmadi A. Zinc and copper levels in Iranian patients with psoriasis: a case control study. Biol Trace Elem Res. 2013 Jun;153(1-3):22-7.3. Wallace HJ. Generalized pustular psoriasis (Von Zumbush) with episodic hypocalcemia. Proc R Soc Med. 1965 Jun;58:425-7.
