Quiz week 29

This non-blanching rash is seen in a 74 year old man who lives alone. You question him about his diet but he has mild depression and cannot remember what he eats.

Q1. Which of the following deficiencies is a likely cause?

1. Zinc
2. Vitamin B
3. Vitamin C
4. Selinium
5. Factor 8 of the coagulation pathway

The answer is Choice 3. Elderly men are usually eating "TV dinners", i.e. frozen meals that have hardly any vitamins. Vitamin C is very likely to be deficient and it leads to perifollicular hemorrhages. That is what has been tried to be shown here.

Q2. In your workup of the patient, you find that the patient has diarrhea, decreased B12 level but elevated Folate level. Which of the following is the most likely cause of the patients B12 deficiency and diarrhea?

1. Hyperthyroidism
2. Pernicious anemia
3. Giardiasis
4. Bacterial overgrowth syndrome
5. Pancreatic exocrine deficiency

This is a common question on British tests. The answer is bacterial overgrowth. Large amounts of bacteria consume B12 but produce Folate. Therefore high Folate in the presence of B12 deficiency. On the schillings test, giving broad spectrum oral antibiotics will correct the abnormality.