{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,12]],"date-time":"2026-02-12T15:30:56Z","timestamp":1770910256504,"version":"3.50.1"},"reference-count":14,"publisher":"BMJ","issue":"2","license":[{"start":{"date-parts":[[2026,2,12]],"date-time":"2026-02-12T00:00:00Z","timestamp":1770854400000},"content-version":"unspecified","delay-in-days":11,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2026,1,30]]},"published-print":{"date-parts":[[2026,2]]},"abstract":"<jats:p>Nutritional deficiencies are common after Roux-en-Y gastric bypass (RYGB) surgery. However, severe zinc deficiency is a diagnostic challenge, given the non-specific skin findings and associated metabolic derangements. We report a case of a female in her 40s with history of RYGB complicated by nutritional deficiencies, alcoholic steatohepatitis, anastomotic ulcers and desquamating skin disorder who presented with altered mental status and haemorrhagic shock secondary to upper gastrointestinal bleed. Her laboratory studies revealed anaemia, hyperammonaemia (337\u2009\u00b5mol\/L) and elevated creatinine with previous biopsy of rash indicating spongiotic dermatitis that improved with inpatient treatment of triamcinolone, clindamycin and vitamin supplementation. Her hospital course was complicated by extended-spectrum beta-lactamase (ESBL) bacteraemia and fungal skin infection requiring several debridement operations of her thighs. Her clinical course remains evolving with recurrent hospital admissions with hyperammonaemia and persistent encephalopathy. In a patient presenting with metabolic derangements and skin rash after RYGB, zinc deficiency is an important differential diagnosis.<\/jats:p>","DOI":"10.1136\/bcr-2025-267538","type":"journal-article","created":{"date-parts":[[2026,2,12]],"date-time":"2026-02-12T14:40:25Z","timestamp":1770907225000},"page":"e267538","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Zinc deficiency with desquamating rash and hyperammonaemia after Roux-en-Y gastric bypass surgery"],"prefix":"10.1136","volume":"19","author":[{"ORCID":"https:\/\/orcid.org\/0009-0004-2939-5314","authenticated-orcid":false,"given":"Radha Roopesh","family":"Patel","sequence":"first","affiliation":[{"name":"Indiana University School of Medicine, Indianapolis, Indiana, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rachel","family":"Palmer","sequence":"additional","affiliation":[{"name":"Indiana University School of Medicine, Indianapolis, Indiana, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Brandon","family":"Umphress","sequence":"additional","affiliation":[{"name":"Indiana University School of Medicine, Indianapolis, Indiana, USA"},{"name":"Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"W Graham","family":"Carlos","sequence":"additional","affiliation":[{"name":"Indiana University School of Medicine, Indianapolis, Indiana, USA"},{"name":"Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2026,2,12]]},"reference":[{"key":"2026021206401644000_19.2.e267538.1","doi-asserted-by":"crossref","first-page":"522","DOI":"10.1007\/s11695-016-2474-8","article-title":"Zinc Deficiency after Gastric Bypass for Morbid Obesity: a Systematic Review","volume":"27","author":"Mahawar","year":"2017","journal-title":"Obes Surg"},{"key":"2026021206401644000_19.2.e267538.2","doi-asserted-by":"crossref","first-page":"107","DOI":"10.1186\/s12902-021-00763-0","article-title":"The prevalence of zinc deficiency in morbidly obese patients before and after different types of bariatric surgery","volume":"21","author":"Soheilipour","year":"2021","journal-title":"BMC Endocr Disord"},{"key":"2026021206401644000_19.2.e267538.3","doi-asserted-by":"crossref","unstructured":"Jiao Y , Liu Y , Chen S , et al . Zinc Deficiency After Bariatric Surgery: A Systematic Review and Meta-analysis. Indian Journal of Surgery 2024;1\u20138. doi:10.1007\/s12262-024-04082-1","DOI":"10.1007\/s12262-024-04082-1"},{"key":"2026021206401644000_19.2.e267538.4","unstructured":"Maxfield L , Shukla S , deficiency C . Zinc deficiency. In: StatPearls. 2022."},{"key":"2026021206401644000_19.2.e267538.5","doi-asserted-by":"crossref","DOI":"10.3390\/nu14224855","article-title":"The Significance of Zinc in Patients with Chronic Liver Disease","volume":"14","author":"Nishikawa","year":"2022","journal-title":"Nutrients"},{"key":"2026021206401644000_19.2.e267538.6","unstructured":"Ali R , Nagalli S . Hyperammonemia. In: StatPearls. StatPearls Publishing, 2023."},{"key":"2026021206401644000_19.2.e267538.7","doi-asserted-by":"crossref","first-page":"493","DOI":"10.1016\/S0140-6736(84)92567-4","article-title":"Oral zinc supplementation improves hepatic encephalopathy: results of a randomised controlled trial","volume":"324","author":"Reding","year":"1984","journal-title":"The Lancet"},{"key":"2026021206401644000_19.2.e267538.8","doi-asserted-by":"crossref","DOI":"10.1177\/23247096221101855","article-title":"Nonhepatic Hyperammonemia With Septic Shock: Case and Review of Literature","volume":"10","author":"Dalsania","year":"2022","journal-title":"J Investig Med High Impact Case Rep"},{"key":"2026021206401644000_19.2.e267538.9","doi-asserted-by":"crossref","unstructured":"Ahmed Z , Ahmed U , Walayat S , et al . Liver function tests in identifying patients with liver disease. Clin Exp Gastroenterol 2018;301\u20137. doi:10.2147\/CEG.S160537","DOI":"10.2147\/CEG.S160537"},{"key":"2026021206401644000_19.2.e267538.10","doi-asserted-by":"crossref","first-page":"1235","DOI":"10.1007\/s40519-021-01154-z","article-title":"Third reported case of rare necrolytic migratory erythema associated with bacteraemia due to severe zinc deficiency after revisional Roux-En-Y gastric bypass: case report and literature review","volume":"27","author":"Salaheldin","year":"2022","journal-title":"Eat Weight Disord"},{"key":"2026021206401644000_19.2.e267538.11","article-title":"Bariatric Surgery Causing Hyperammonemia","volume":"11","author":"Krishnan","year":"2019","journal-title":"Cureus"},{"key":"2026021206401644000_19.2.e267538.12","doi-asserted-by":"crossref","first-page":"24707","DOI":"10.3402\/jchimp.v4.24707","article-title":"Zinc-deficiency acrodermatitis in a patient with chronic alcoholism and gastric bypass: a case report","volume":"4","author":"Shahsavari","year":"2014","journal-title":"J Community Hosp Intern Med Perspect"},{"key":"2026021206401644000_19.2.e267538.13","doi-asserted-by":"publisher","DOI":"10.1111\/j.1524-475X.2006.00179.x"},{"key":"2026021206401644000_19.2.e267538.14","unstructured":"Jagadeesan S , Kaliyadan F . 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