# Bilateral Blistering Rash Following Gastric Bypass Procedure and Mushroom Soup Diet: Hepatitis C Virus-Seronegative Necrolytic Acral Erythema

## TL;DR

A 66-year-old man developed a skin condition after gastric bypass and a mushroom soup diet, which improved with zinc treatment.

## Contribution

This case highlights NAE as a complication of gastric bypass-related nutritional deficiency, not linked to HCV.

## Key findings

- The patient's NAE was associated with a gastric bypass and mushroom soup diet, not HCV.
- Zinc replacement therapy improved the skin lesions after other treatments failed.
- Biopsy confirmed epidermal necrosis and vacuolopathy consistent with NAE.

## Abstract

Necrolytic acral erythema (NAE) is an uncommon cutaneous disorder characterized by a symmetric acral distribution of erythematous plaques with underlying epidermal necrosis. While typically presenting in the context of hepatitis C virus (HCV) infection, NAE can also present secondary to nutritional deficiency or systemic disease. We present a case of NAE in a 66-year-old patient with no history of HCV infection status post gastric bypass who had a three-month history of eating only mushroom soup. The patient underwent a punch biopsy and was tested for a variety of nutritional deficiencies. Biopsy demonstrated partial necrosis of the upper epidermis, with subjacent re-epithelialization, squamatization, and vacuolopathy of the basal epidermis. He was treated with zinc replacement therapy after initial trials of tacrolimus and clobetasol were unsuccessful. At follow-up, he had significant improvement of the lesions. This case provides an example of an atypical presentation of NAE in the absence of HCV infection that presented as a complication of gastric bypass-associated nutritional deficiency.