Difference between kwashiorkor and marasmus: Comparative meta-analysis of pathogenic characteristics and implications for treatment.

Kwashiorkor and marasmus are two clinical syndromes observed in severe acute malnutrition. In this review, we highlighted the differences between these two syndromes by reviewing the data comparing kwashiorkor and marasmus in literature, combined with recent microbiological findings and meta-analysis. Depletion of antioxidants, vitamins and minerals were more severe in kwashiorkor than marasmus. This was consistent with the severe and uncontrolled oxidative stress associated with the depletion of gut anaerobes and the relative proliferation of aerotolerant gut pathogens. This relative proliferation and invasion of gut microbes belonging to the aerotolerant Proteobacteria phylum and pathogens suggested a specific microbial process critical in the pathogenesis of kwashiorkor. Liver mitochondrial and peroxisomal dysfunction could be secondary to toxic microbial compounds produced in the gut such as ethanol, lipopolysaccharides and endotoxins produced by Proteobacteria, particularly Klebsiella pneumoniae, and aflatoxin produced by Aspergillus species. The gut-liver axis alteration is characterized by oedema and a fatty and enlarged liver and was associated with a dramatic depletion of methionine and glutathione, an excessive level of free circulating iron and frequent lethal bacteraemia by enteric pathogens. This was consistent with the fact that antibiotics improved survival only in children with kwashiorkor but not marasmus. The specific pathogenic characteristics of kwashiorkor identified in this review open new avenues to develop more targeted and effective treatments for both marasmus and/or kwashiorkor. Urgent correction of plasma glutathione depletion, alongside supply of specific essential amino acids, particularly methionine and cysteine, early detection of pathogens and an antibiotic more efficient than amoxicillin in supressing gut Proteobacteria including K. pneumoniae, and probiotics to restore the human gut anaerobic mature microbiota could save many more children with kwashiorkor.

Cutaneous presentation of kwashiorkor due to infantile Crohn's disease.

Kwashiorkor is one of the severe forms of protein-energy malnutrition. Many characteristic dermatoses can be seen in children suffering from kwashiorkor, and some are pathognomonic. Here, we report an infant who presented with diarrhea and skin signs of kwashiorkor, and duodenal biopsy was consistent with Crohn's disease. The patient was treated with prednisolone administered orally in a tapering course plus azathioprine, in addition to nutritional supplementation. The general condition of the patient quickly improved and his skin lesions completely resolved within 2 weeks. Kwashiorkor is a serious potentially fatal disease that occurs less often in developed countries leading to low index of suspicion by physicians and pediatricians in those regions. Occasionally, dermatologists have the rare chance of alerting pediatricians to the diagnosis of kwashiorkor, thus making a difference in the care of this disease.

Kwashiorkor and an acrodermatitis enteropathica-like eruption after a distal gastric bypass surgical procedure.

OBJECTIVE: To describe a case of kwashiorkor and an acrodermatitis enteropathica-like eruption associated with zinc deficiency after a distal gastric bypass surgical procedure. METHODS: A case report of a morbidly obese patient who underwent a gastric bypass operation is presented, including clinical, laboratory, and radiologic findings. In addition, the literature on potential nutritional deficiencies after bariatric surgical intervention is reviewed. RESULTS: A 43-year-old woman with a history of morbid obesity underwent a distal Roux-en-Y gastric bypass procedure at an outside institution. Six months later, she presented to our clinic because of abdominal pain, lower extremity edema, and a patchy maculopapular scaling rash. She had not adhered to a vitamin supplementation regimen prescribed postoperatively. Her symptoms progressively worsened, and she was hospitalized for management of severe malnutrition and dehydration. Laboratory tests revealed low levels of albumin, hemoglobin, vitamin A, vitamin D, copper, and zinc and elevated levels of liver enzymes. Anasarca and bowel wall edema were seen on an abdominal computed tomographic scan, and an upper endoscopy revealed a stomal ulcer and a stricture at the site of the gastrojejunal anastomosis. The patient was diagnosed as having kwashiorkor, zinc deficiency, and an acrodermatitis enteropathica-like eruption. Treatment was begun with total parenteral nutrition, which led to alleviation of her symptoms. Approximately 3 months later, she underwent gastric bypass revision but had numerous postoperative complications. CONCLUSION: Kwashiorkor and severe nutritional deficiencies were noted in this patient after a distal gastric bypass surgical procedure. This clinical presentation is uncommon and can be attributed to the increased malabsorption that occurs with distal gastric bypass, the development of mechanical complications, and the inadequacy of nutritional supplementation. After a bariatric operation, careful adherence to follow-up regimens and the involvement of a multidisciplinary team can improve the chances of a successful outcome.

Effects of antioxidants on glutathione levels and clinical recovery from the malnutrition syndrome kwashiorkor--a pilot study.

Kwashiorkor is a severe edematous form of malnutrition with high prevalence and lethality in many African countries, and repeatedly has been reported to be associated with oxidative stress. The therapy of kwashiorkor is still ineffective. In this pilot study, we tested the hypothesis that oral application of thiol-containing antioxidants increases glutathione status and is beneficial for the clinical recovery of kwashiorkor patients. The longitudinal clinical intervention study was carried out at St Joseph's Hospital, Jirapa, Ghana. Children with severe kwashiorkor were randomly assigned to either a standard treatment (ST) receiving a therapeutic protocol based on the recommendations of the WHO or to one of three study groups receiving in addition 2 x 600 mg reduced glutathione or 2 x 50 mg alpha-lipoic acid or 2 x 100 mg N-acetylcysteine per day. Patients were followed up clinically and biochemically for 20 days and compared with 37 healthy controls. Both glutathione and alpha-lipoic acid supplementation had positive effects on survival. Also, the blood glutathione concentrations correlated positively with survival rates. Furthermore, the initial skin lesions, glutathione and total protein concentrations were found to be strong predictors of survival. The data strongly suggest that a therapy restoring the antioxidative capacity by applying cysteine equivalents in the form of glutathione and/or alpha-lipoic acid is beneficial for biochemical and clinical recovery of kwashiorkor patients.

Hypoinsulinaemia has an important role in the development of oedema and hepatomegaly during malnutrition.

Various alterations in hormonal levels have been suggested to contribute to the development of nutritional oedema and fatty liver in children with kwashiorkor. We present an infant who underwent near-total pancreatectomy at the age of 4 weeks and developed kwashiorkor after 11 weeks. The sequence of events following surgery can be divided into two phases. The first phase was characterized by hyperinsulinaemia and hypoglycaemia before feeds. During this phase, although the weight gain was slow (10 g/day) serum albumin (32 g/I) and prealbumin (0.23 g/I) concentrations were maintained with no oedema or hepatomegaly. In the second phase, insulin deficiency prevailed and he was receiving the same amount of milk (protein)/day (enriched with starch). During that phase he rapidly developed hypoalbuminaemia (18 g/l), hypoprealbuminaemia (0.1 g/l), oedema, hepatomegaly, and dermatosis. This case demonstrates clearly the important role of defective insulin secretion in the development of nutritional oedema and hepatomegaly.

Fósforo sérico en niños con malnutrición de III grado / Serum phosphorus in grade malnourished children

El presente es un estudio prospectivo, longitudinal y comparativo en el que se determino el nivel de fósforo sérico en niños con mal nutrición de III grado (Marasmo, Mixto y Kwashiorkor) con y sin diarrea y que requirieron hidratación parental, suplementandose o no el fósforo con fines de comparación. Se encontró niveles bajos de fósforo (0,93 mMo1/L) en grupo de niños desnutridos y sin diarrea (normal 1,3 - 2,3 mMo1/L). En los niños con diarrea y deshidratación que recibierón hidratación parental sin suplemento de fósforo, los niveles séricos de este bajarón de 1,23 a 0.91 en los que presentaban edemas y de 1,07 a 0,8 en los que no lo contenian. Mientras que en aquellos que presentaban el mismo cuadro pero a quienes se suplementó el fósforo, el promedio mejoró de 0,8 a 1.08 en los que tenian edemas, sin embargo hubo un descenso en los que no tenian edemas de 1,03 a 0,58. La hipofosfatemia se relacionó marcadamente con la hipotonía muscular, mejorando el toniasmo en los niños que fueron suplementados.

Secretory IgA synthesis in Kwashiorkor.

The synthesis of intestinal secretory IgA was studied in in vitro cultures of duodenal mucosal biopsies from children with Kwashiorkor. Production of secretory IgA was measured by the incorporation of radioactive label and visualized following PAGE and autoradiography. Results obtained before and after nutritional rehabilitation demonstrate an enhanced synthesis of sIgA in children with acute Kwashiorkor. Histological examination of plasma cells in the biopsy tissue confirms a twofold increase in IgA staining plasma cells in acute Kwashiorkor. Peripheral blood B lymphocytes in acute Kwashiorkor however, showed a reduction in IgA synthesis in the acute stage. These results suggest an effective mucosal sIgA response to the increased intestinal antigen load in Kwashiorkor.