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Ingestion of a dietary supplement resulting in selenium toxicity
168 Letters
J AM ACAD DERMATOL JULY 2010
4. Won TH, Seo PS, Park SD, Kim DL, Park JH. Clinical features of 147 patients with systemic contact dermatitis due to the ingestion of chicken boiled with Japanese lacquer tree. Korean J Dermatol 2008;46:761-8. 5. Park YM, Park JG, Kang H, Houh D, Byun DG, Kim JW. Acute generalized exanthematous pustulosis induced by ingestion of lacquer chicken. Br J Dermatol 2002;143:230-2. 6. Gladman AC. Toxicodendron dermatitis: poison ivy, oak, and sumac. Wilderness Environ Med 2006;17:120-8. doi:10.1016/j.jaad.2009.03.023
Ingestion of a dietary supplement resulting in selenium toxicity
Fig 1. Horizontal bands seen on the nails of the right hand (patient 1).
To the Editor: In April 2008, the US Food and Drug Administration warned consumers not to ingest certain flavors of the nutritional supplements ‘‘Total Body Formula’’ and ‘‘Total Body Mega Formula’’ because they contained more than 200 times the 200 g of selenium indicated on the label.1,2 Elevated levels of chromium were also discovered—up to 17 times the amount stated on the label. The distributor of the vitamins voluntarily recalled the products.3 We describe two patients who developed signs consistent with selenium poisoning after consuming the ‘‘Total Body Formula’’ dietary supplement. Patient 1 was a 45-year-old woman who presented with a 4-week history of a diffuse erythematous, pruritic, exfoliative eruption of the scalp with progressive hair loss. She reported discoloration of the nails, dizziness, fatigue, amenorrhea, and dental caries. The patient stated that the hair loss and scalp problems appeared 7 days after she began ingesting the ‘‘Total Body Formula’’ nutritional supplement. The patient did not associate the development of these medical problems with the supplement, and continued to consume the product for approximately 30 consecutive days, nearly completing a 0.95-L container. She presented to our clinic approximately 2 days after completing her last dose of the supplement. Selenium toxicity was not suspected until her following examination, approximately 25 days later. The physical examination revealed seborrhea-like scaling with some acneiform papules on the scalp. Hair loss was noted, with pulled hairs being predominantly in the anagen phase. Most of her fingernails possessed a grayish-white discoloration in transverse bands approximately 2- to 4-mm distal to the cuticle (Fig 1). Serum and urine levels analyzed for selenium 5 weeks after last ingestion of the product were within normal limits. A selenium hair test, performed 6 weeks after last dose of the supplement, revealed an elevated selenium level at 3.2 g/g (reference range,
0.4-1.4 g/g). Before the hair analysis, the ingredients of the shampoos the patient used during the previous 2 months were tested, and we determined that they contained no selenium sulfide. Pertinent demographic and clinical information about patient 2 is presented in Table 1. Figure 2 illustrates patient 2’s diffuse alopecia. The clinical manifestations of selenium toxicity vary greatly, including cramping, nausea, vomiting, diarrhea, joint pain, and fatigue.4 Additional possible symptoms include blistering skin lesions, nail changes, hair loss, and possible dental caries.4,5 Although patient 1 exhibited numerous physical signs of selenium poisoning, her serum selenium and urine levels were normal, likely because the laboratory values were assessed 5 weeks after the last dose of the supplement. The element had therefore already been metabolized and excreted. However, a hair analysis did reveal significantly elevated selenium levels. There is no proven treatment for selenium poisoning. Symptoms associated with this condition as a rule gradually improve over time with supportive care.4 Patient 1’s hair loss and nail discoloration began to improve approximately 5 weeks after consuming her last dose of the product, and by 6 months later most of her symptoms had resolved. We report two cases of selenium toxicity that occurred after ingestion of the ‘‘Total Body Formula’’ dietary supplement.1 Physicians should be familiar with the symptoms of selenium poisoning in order to recognize this diagnosis. R. Erin Lopez, Alfred L. Knable, Jr, MD, and Joyti B. Burruss, MD Department of Dermatology, University of Louisville, Louisville, Kentucky Funding source: None. Conflicts of interest: None declared.
Letters 169
J AM ACAD DERMATOL VOLUME 63, NUMBER 1
Table 1. Demographic and clinical information for patients 1 and 2 Patient 1
Duration of ingestion Clinical presentation
Physical examination
Discovery of selenium toxicity Laboratory values
Resolution of symptoms
Patient 2
1 month 45-year-old woman with a 4-week history of a diffuse erythematous, pruritic, exfoliative eruption of the scalp and hair loss; discoloration of nails, dizziness, fatigue, amenorrhea, and numerous dental carries; last dose of supplement just before presentation Scalp: patchy, seborrhea-like scaling with acneiform papules; hair: alopecia and pulled hairs of anagen phase; nails: most nails possessed a grayish-white discoloration in transverse bands 2 to 4 mm distal to the cuticle 25 days after the initial examination Serum and urine selenium levels were normal—tests were performed 5 weeks after last ingestion; selenium hair test: 3.2 g/g (reference range, 0.4-1.4 g/g) —performed 6 weeks after last ingestion Hair loss and nails began to improve 5 weeks after the last dose, and the majority of symptoms completely resolved 6 months after the last dose
3.5 months 56-year-old woman with a 3-month history of hair loss; discoloration of nails, metatarsal cramping, fatigue, and malaise; last dose of the supplement just before presentation
Hair: diffuse alopecia and pulled hairs of anagen phase; nails: all nails had 3 mm of normal nail at the base but were distally thickened and yellow (nail changes were not noted until 49 days after initial presentation) 49 days after the initial examination Serum selenium: 166 g/L (reference range, 110-160 g/L)—performed 7 weeks after last ingestion; hair was unattainable for testing
Hair loss and nails began to improve 2 months after the last dose; hair and nail growth were completely normal 7 months after the last dose
3. US Food and Drug Administration. FDA warns consumers about ‘‘Total Body Formula’’ and ‘‘Total Body Mega Formula.’’ March 27, 2008. Available at: http://www.fda.gov/bbs/topics/ NEWS/2008/NEW01812.html. Accessed June 27, 2008. 4. Centers for Disease Control and Prevention. Toxic levels of selenium in dietary supplements. April 17, 2008. Available at: http://emergency.cdc.gov/agent/selenium/supplements2008.asp. Accessed June 27, 2008. 5. Yang GQ, Wang SZ, Zhou RH, Sun SZ. Endemic selenium intoxication of humans in China. Am J Clin Nutr 1983;37:872-81. doi:10.1016/j.jaad.2009.03.045
Fig 2. Diffuse alopecia seen in patient 2.
Correspondence to: Alfred L. Knable, Jr, MD, Associates in Dermatology, 310 E Broadway, Louisville, KY 40202 E-mail: [email protected] REFERENCES 1. Centers for Disease Control and Prevention. CDC alert on adverse effects associated with consuming ‘‘Total Body Formula’’ and ‘‘Total Body Mega Formula.’’ April 14, 2008. Available at:http://www2a.cdc.gov/HAN/ArchiveSys/ViewMsgV.asp?Alert Num¼00274. Accessed June 27, 2008. 2. Total Body Essential Nutrition, Inc. Total Body Formula: supplement facts. Available at: http://www.totalbodyteam.com/pro duct_info. Accessed October 26, 2008.
Molluscum contagiosum folliculitis mimicking tinea barbae in a lung transplant recipient To the Editor: Viral folliculitis is an infrequent condition; in particular, folliculitis caused by molluscum contagiosum virus (MCV) has rarely been described.1-4 Most cases of folliculitis caused by MCV develop in patients with acquired or iatrogenic immunosuppression. A 61-year-old man presented with multiple, fleshto red-colored papules 2- to 5-mm in diameter, some of them umbilicated, symmetrically disseminated on the chin and cheeks. A physical examination revealed papules with a central cavity of heterogeneous size (Fig1). His medical history included a bilateral lung
J AM ACAD DERMATOL JULY 2010
4. Won TH, Seo PS, Park SD, Kim DL, Park JH. Clinical features of 147 patients with systemic contact dermatitis due to the ingestion of chicken boiled with Japanese lacquer tree. Korean J Dermatol 2008;46:761-8. 5. Park YM, Park JG, Kang H, Houh D, Byun DG, Kim JW. Acute generalized exanthematous pustulosis induced by ingestion of lacquer chicken. Br J Dermatol 2002;143:230-2. 6. Gladman AC. Toxicodendron dermatitis: poison ivy, oak, and sumac. Wilderness Environ Med 2006;17:120-8. doi:10.1016/j.jaad.2009.03.023
Ingestion of a dietary supplement resulting in selenium toxicity
Fig 1. Horizontal bands seen on the nails of the right hand (patient 1).
To the Editor: In April 2008, the US Food and Drug Administration warned consumers not to ingest certain flavors of the nutritional supplements ‘‘Total Body Formula’’ and ‘‘Total Body Mega Formula’’ because they contained more than 200 times the 200 g of selenium indicated on the label.1,2 Elevated levels of chromium were also discovered—up to 17 times the amount stated on the label. The distributor of the vitamins voluntarily recalled the products.3 We describe two patients who developed signs consistent with selenium poisoning after consuming the ‘‘Total Body Formula’’ dietary supplement. Patient 1 was a 45-year-old woman who presented with a 4-week history of a diffuse erythematous, pruritic, exfoliative eruption of the scalp with progressive hair loss. She reported discoloration of the nails, dizziness, fatigue, amenorrhea, and dental caries. The patient stated that the hair loss and scalp problems appeared 7 days after she began ingesting the ‘‘Total Body Formula’’ nutritional supplement. The patient did not associate the development of these medical problems with the supplement, and continued to consume the product for approximately 30 consecutive days, nearly completing a 0.95-L container. She presented to our clinic approximately 2 days after completing her last dose of the supplement. Selenium toxicity was not suspected until her following examination, approximately 25 days later. The physical examination revealed seborrhea-like scaling with some acneiform papules on the scalp. Hair loss was noted, with pulled hairs being predominantly in the anagen phase. Most of her fingernails possessed a grayish-white discoloration in transverse bands approximately 2- to 4-mm distal to the cuticle (Fig 1). Serum and urine levels analyzed for selenium 5 weeks after last ingestion of the product were within normal limits. A selenium hair test, performed 6 weeks after last dose of the supplement, revealed an elevated selenium level at 3.2 g/g (reference range,
0.4-1.4 g/g). Before the hair analysis, the ingredients of the shampoos the patient used during the previous 2 months were tested, and we determined that they contained no selenium sulfide. Pertinent demographic and clinical information about patient 2 is presented in Table 1. Figure 2 illustrates patient 2’s diffuse alopecia. The clinical manifestations of selenium toxicity vary greatly, including cramping, nausea, vomiting, diarrhea, joint pain, and fatigue.4 Additional possible symptoms include blistering skin lesions, nail changes, hair loss, and possible dental caries.4,5 Although patient 1 exhibited numerous physical signs of selenium poisoning, her serum selenium and urine levels were normal, likely because the laboratory values were assessed 5 weeks after the last dose of the supplement. The element had therefore already been metabolized and excreted. However, a hair analysis did reveal significantly elevated selenium levels. There is no proven treatment for selenium poisoning. Symptoms associated with this condition as a rule gradually improve over time with supportive care.4 Patient 1’s hair loss and nail discoloration began to improve approximately 5 weeks after consuming her last dose of the product, and by 6 months later most of her symptoms had resolved. We report two cases of selenium toxicity that occurred after ingestion of the ‘‘Total Body Formula’’ dietary supplement.1 Physicians should be familiar with the symptoms of selenium poisoning in order to recognize this diagnosis. R. Erin Lopez, Alfred L. Knable, Jr, MD, and Joyti B. Burruss, MD Department of Dermatology, University of Louisville, Louisville, Kentucky Funding source: None. Conflicts of interest: None declared.
Letters 169
J AM ACAD DERMATOL VOLUME 63, NUMBER 1
Table 1. Demographic and clinical information for patients 1 and 2 Patient 1
Duration of ingestion Clinical presentation
Physical examination
Discovery of selenium toxicity Laboratory values
Resolution of symptoms
Patient 2
1 month 45-year-old woman with a 4-week history of a diffuse erythematous, pruritic, exfoliative eruption of the scalp and hair loss; discoloration of nails, dizziness, fatigue, amenorrhea, and numerous dental carries; last dose of supplement just before presentation Scalp: patchy, seborrhea-like scaling with acneiform papules; hair: alopecia and pulled hairs of anagen phase; nails: most nails possessed a grayish-white discoloration in transverse bands 2 to 4 mm distal to the cuticle 25 days after the initial examination Serum and urine selenium levels were normal—tests were performed 5 weeks after last ingestion; selenium hair test: 3.2 g/g (reference range, 0.4-1.4 g/g) —performed 6 weeks after last ingestion Hair loss and nails began to improve 5 weeks after the last dose, and the majority of symptoms completely resolved 6 months after the last dose
3.5 months 56-year-old woman with a 3-month history of hair loss; discoloration of nails, metatarsal cramping, fatigue, and malaise; last dose of the supplement just before presentation
Hair: diffuse alopecia and pulled hairs of anagen phase; nails: all nails had 3 mm of normal nail at the base but were distally thickened and yellow (nail changes were not noted until 49 days after initial presentation) 49 days after the initial examination Serum selenium: 166 g/L (reference range, 110-160 g/L)—performed 7 weeks after last ingestion; hair was unattainable for testing
Hair loss and nails began to improve 2 months after the last dose; hair and nail growth were completely normal 7 months after the last dose
3. US Food and Drug Administration. FDA warns consumers about ‘‘Total Body Formula’’ and ‘‘Total Body Mega Formula.’’ March 27, 2008. Available at: http://www.fda.gov/bbs/topics/ NEWS/2008/NEW01812.html. Accessed June 27, 2008. 4. Centers for Disease Control and Prevention. Toxic levels of selenium in dietary supplements. April 17, 2008. Available at: http://emergency.cdc.gov/agent/selenium/supplements2008.asp. Accessed June 27, 2008. 5. Yang GQ, Wang SZ, Zhou RH, Sun SZ. Endemic selenium intoxication of humans in China. Am J Clin Nutr 1983;37:872-81. doi:10.1016/j.jaad.2009.03.045
Fig 2. Diffuse alopecia seen in patient 2.
Correspondence to: Alfred L. Knable, Jr, MD, Associates in Dermatology, 310 E Broadway, Louisville, KY 40202 E-mail: [email protected] REFERENCES 1. Centers for Disease Control and Prevention. CDC alert on adverse effects associated with consuming ‘‘Total Body Formula’’ and ‘‘Total Body Mega Formula.’’ April 14, 2008. Available at:http://www2a.cdc.gov/HAN/ArchiveSys/ViewMsgV.asp?Alert Num¼00274. Accessed June 27, 2008. 2. Total Body Essential Nutrition, Inc. Total Body Formula: supplement facts. Available at: http://www.totalbodyteam.com/pro duct_info. Accessed October 26, 2008.
Molluscum contagiosum folliculitis mimicking tinea barbae in a lung transplant recipient To the Editor: Viral folliculitis is an infrequent condition; in particular, folliculitis caused by molluscum contagiosum virus (MCV) has rarely been described.1-4 Most cases of folliculitis caused by MCV develop in patients with acquired or iatrogenic immunosuppression. A 61-year-old man presented with multiple, fleshto red-colored papules 2- to 5-mm in diameter, some of them umbilicated, symmetrically disseminated on the chin and cheeks. A physical examination revealed papules with a central cavity of heterogeneous size (Fig1). His medical history included a bilateral lung