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Curly hair caused by selenium deficiency in an adult woman

Dear Editor, Selenium deficiency can cause myalgias, hemolysis, impaired immune function, and fatal cardiomyopathy; therefore, appropriate diagnosis and treatment are important. A 42yearold Japanese woman with a history of subtotal gastrectomy with RouxenY reconstruction and multiple small intestinal resections (three times) due to chronic multiple ulcers of the small intestine was admitted to our hospital for catheterrelated blood stream infection. Because of uncontrollable adhesional ileus and chronic abdominal pain, she had been receiving home parenteral nutrition via a central vein (CV) port for 7 years. She initially received parenteral nutrition with low residue diet, however, 6 months before admission, she started to receive most of her nutrition using a CV nutrition kit formulation, which did not contain selenium, as her abdominal pain worsened. The infection was improved by the CV port replacement and antibiotic treatment. She originally had straight brownish hair. On physical examination upon admission, she had curly hair with light brown color (Figure 1a), but no alopecia or canities, although she did not dye her hair. She did not have any changes of skin and nail appearance. Laboratory data revealed low levels of serum selenium (<2.0 μg/dL; normal, 10.0– 16.0). No significant changes were observed in other micronutrient and electrolytes (Table S1). Then, i.v. administration of selenium (sodium selenite 50– 100 μg/day) was started to be added into the parenteral nutrition. The serum selenium level was improving, and her curly hair was gradually changing back to straight hair for 8 months after selenium administration (Figure 1b,c). Selenium has pleiotropic effects, such as antioxidant/antiinflammatory effects and production of active thyroid hormone, through selenoproteins.1 Selenium deficiency was reported to be associated with increased risk of mortality, thyroid autoimmune disease, poor immune function, and cardiomyopathy.1 The skin appearance of selenium deficiency is typically known to be white nail beds, pseudoalbinism, and altered hair appearance; however, curly hair change is very rare. The present case did not have such typical findings, implying that curly hair might be one of the early clinical signs of suspected selenium deficiency. Although the exact mechanism of curly hair caused by micronutrient deficiency has not been established,2 there are several possible mechanisms. Dysfunction of selenoproteins by selenium deficiency might cause structural/functional abnormalities in hair follicles, such as uneven expression of keratins, asymmetric distribution of cortical cells, and asymmetric location of dermal papilla cells. Hypothyroidism, which can be caused by selenium deficiency, might change hair appearance. Selenium is mainly absorbed in the small intestine, and the serum level can be influenced by inflammatory status and malnutrition.3 Patients with total parenteral nutrition4 have also been reported to be at risk of selenium deficiency. Therefore, clinicians should pay attention to symptoms and physical findings related to selenium deficiency; however, not all patients develop typical symptoms.5 In the present rare case, a slight change of hair appearance, but not major symptoms, gave an opportunity to recognize micronutrient deficiency before any serious complications appeared.