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History of Present Illness: A 24-month-old boy presents to the clinic you are working in rural Tanzania. He weighs 8.5kg. He was brought to clinic today by his mother because he has had decreased energy for a few weeks and has been very irritable and fussy. She has reports that he has had a “swollen belly for a long time”. He typically eats a chapatti for breakfast and a small bowel of local porridge for lunch and dinner. His other notable symptoms include multiple episodes of diarrhea for one week that is non-bloody and watery and a fever and cough that he has had for a few days. In addition, his oral intake has decreased the past few days and he was becoming sleepier at home today. Physical Exam: Vital Signs: Temp: 38.7 HR: 150 RR: 35 BP: 90/70 Pulse ox: 95% on room air General: Patient is tired in appearance but arousable on examination. HEENT: Normocephalic, TMs clear, Hair is reddish in appearance and ruddy colored. He has bilateral periorbital edema. His face is swollen. Neck: Generalized LAD. Lungs: CTAB, no wheezing, no retractions noted Heart: tachycardia, no murmur, peripheral pulses are 2+ Abdomen: firm, distended, nontender, has bowel sounds, liver is enlarged and down 4 cm. Skin: Areas of dry peeling skin on extremities bilaterally with patches of hyperpigmentation. Extremities: generalized edema with 3+ edema in arms and legs bilaterally. Pedal edema is pitting.  Questions: What is the most likely diagnosis of this patient? What physical exam findings support the diagnosis? What is the typical treatment for the patient’s condition? Does this patient meet inpatient treatment criteria? Answers:
What is the most likely diagnosis of this patient? This patient has a condition called kwashiorkor. Kwashiorkor is a form of malnutrition that is secondary to inadequate protein and micronutrient deficiency. The inadequate amount of protein in the diet not only leads to malnutrition but also results in hypoalbuminemia that leads to third spacing and accumulation of extravascular fluid causing the edematous presentation in patients. This leads to physical exam findings such as moon facies and pitting edema. Typically the patient also has concurrent zinc deficiency that can cause dermatitis leading to desquamation of the skin and either hyper or hypopigmentation. Hepatomegaly is another common physical exam finding that is caused from fatty infiltration of the liver. These patients are often apathetic, listless, and irritable. Hair often becomes dry and brittle and sometimes changes to a ruddy, orange color. What physical exam findings support the diagnosis? Typically Kwashiorkor is a clinical diagnosis based on physical exam findings, weight for age, and history. Other diagnosis for generalized edema should be considered, but in a rural area known to have a large population with malnutrition, this is typically the most likely diagnosis. Patients typically have electrolyte abnormalities, vitamin deficiencies, and often will be anemic. If the clinic/hospital you are working in has the capability to send for labs, a CMP, CBC, Mg, and Phos would be useful. Often these children present with dehydration with concurrent hypovolemic shock. Children with kwashiorkor are prone to developing infection and can also present with fever due to septic shock, pneumonia, cellulitis due to infection of sloughing skin, or other infections. Alternatively, these children can also be hypothermic due to infection, hypoglycemia, or lack of fat/muscle mass. What is the typical treatment for the patient’s condition? Treatment is many fold and is directed primarily at correcting electrolyte/glucose abnormalities, rehydrating if dehydrated, treating with antibiotics if infection is suspected, deworming, correcting vitamin/micronutrient deficiencies, and providing adequate nutrition to promote weight gain. Patients should be monitored closely during stabilization process. Most hospitals have a protocol for malnutrition that assists in helping children to gain weight slowly and safely. Does this patient meet inpatient treatment criteria? Children meet criteria for inpatient treatment if they have a poor appetite and fail an appetite test in clinic, if they have severe medical complications, if there is edema present on physical exam, or if they are failing outpatient management. Medical complications include intractable vomiting, signs concerning for severe dehydration, fever or hypothermia, signs of severe lower respiratory tract infection such as tachypnea/hypoxia/respiratory distress, severe anemia, or altered mental status/lethargy.
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Blog posts from the resident and faculty physicians of the Carolinas Medical Center global health interest group.
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