An unusual case of pericardial effusion.

We report a case of a 13-year-old male with trisomy 21 in Southwestern Ontario, Canada, who presented with bilateral pneumonia, pericardial effusion, and peripheral oedema. The pericardial effusion did not respond to standard treatment options. Evaluation revealed severe dietary restriction, consistent with kwashiorkor. Hospital course was complicated by severe hypoalbuminaemia, hypocalcaemia, hypomagnesaemia, and hypophosphataemia. The pericardial effusion and other findings resolved gradually upon slow introduction of a well-balanced diet and adequate caloric and protein intake. Kwashiorkor is an unusual cause of pericardial effusion and can be overlooked especially in developed countries. It is a type of protein-calorie malnutrition often seen in children of impoverished countries and famine. It is a result of insufficient protein intake in the context of adequate caloric intake. Pericardial effusion not responding to usual treatment is a challenge, and other aetiologies must be considered. Malnutrition is often underdiagnosed or misdiagnosed in developed countries with devastating outcomes if unrecognised. This makes it imperative to consider this diagnosis, recognise potential risk factors, and be prepared to accurately assess overall nutritional status.

A child with kwashiorkor misdiagnosed as atopic dermatitis.

Although uncommon, kwashiorkor continues to occur in developed, but mainly in developing nations. It is a type of protein-calorie malnutrition that occurs in the setting of insufficient protein intake in the presence of sufficient caloric intake. Skin and hair changes should prompt a thorough dietary history and appropriate dietary intervention. We report a case of a 12-month old girl in Belo Horizonte, Minas Gerais, Brazil, who presented with diffuse edema, desquamation, and irritability misdiagnosed as atopic dermatitis. The diagnosis was consistent with kwashiorkor as a result of severe dietary restriction. The mother had placed the child on a severely restrictive diet, consisting only of potatoes, gelatin, and juice as a consequence of the inability to breastfeed. Kwashiorkor is often underdiagnosed or misdiagnosed and if unrecognized or untreated, may be devastating. This makes it imperative that physicians consider this diagnosis, recognize potential risk factors, and be prepared to accurately assess overall nutritional status of patients.

[Acute malnutrition in children].

The prevalence of malnutrition has declined significantly over the last 30 years. Despite this, malnutrition remains a major cause of illness and death among children worldwide, particularly in low- and medium-income countries. Marasmus and kwashiorkor are the most life-threatening forms of malnutrition. Treatment protocols enable effective treatment, but only a minority of malnourished children have access to treatment. Furthermore, treating children with complicated malnutrition requiring hospitalization remains a clinical challenge.

Metabolomic Changes in Serum of Children with Different Clinical Diagnoses of Malnutrition.

BACKGROUND: Mortality in children with severe acute malnutrition (SAM) remains high despite standardized rehabilitation protocols. Two forms of SAM are classically distinguished: kwashiorkor and marasmus. Children with kwashiorkor have nutritional edema and metabolic disturbances, including hypoalbuminemia and hepatic steatosis, whereas marasmus is characterized by severe wasting. The metabolic changes underlying these phenotypes have been poorly characterized, and whether homeostasis is achieved during hospital stay is unclear. OBJECTIVES: We aimed to characterize metabolic differences between children with marasmus and kwashiorkor at hospital admission and after clinical stabilization and to compare them with stunted and nonstunted community controls. METHODS: We studied children aged 9-59 mo from Malawi who were hospitalized with SAM (n = 40; 21 with kwashiorkor and 19 with marasmus) or living in the community (n = 157; 78 stunted and 79 nonstunted). Serum from patients with SAM was obtained at hospital admission and 3 d after nutritional stabilization and from community controls. With the use of targeted metabolomics, 141 metabolites, including amino acids, biogenic amines, acylcarnitines, sphingomyelins, and phosphatidylcholines, were measured. RESULTS: At admission, most metabolites (128 of 141; 91%) were lower in children with kwashiorkor than in those with marasmus, with significant differences in several amino acids and biogenic amines, including those of the kynurenine-tryptophan pathway. Several phosphatidylcholines and some acylcarnitines also differed. Patients with SAM had profiles that were profoundly different from those of stunted and nonstunted controls, even after clinical stabilization. Amino acids and biogenic amines generally improved with nutritional rehabilitation, but most sphingomyelins and phosphatidylcholines did not. CONCLUSIONS: Children with kwashiorkor were metabolically distinct from those with marasmus, and were more prone to severe metabolic disruptions. Children with SAM showed metabolic profiles that were profoundly different from stunted and nonstunted controls, even after clinical stabilization. Therefore, metabolic recovery in children with SAM likely extends beyond discharge, which may explain the poor long-term outcomes in these children. This trial was registered at isrctn.org as ISRCTN13916953.

Kwashiorkor: an unexpected complication to anorexia nervosa.

We present the case of a woman aged 48 years, diagnosed with anorexia nervosa (AN) at the age of 12. She was admitted to a highly specialised eating disorder facility with distended abdomen, muscular atrophy, ulcerative dermatitis, electrolyte derangements and low serum albumin. Her weight was 53.1 kg, corresponding to a body mass index (BMI) of 17.9 kg/m2 After initial stabilisation, a therapeutic ascites puncture relieved the patient from 6500 mL of ascites. After 6 weeks of nutritional and diuretic treatment, the patient was discharged with a weight of 46.8 kg (BMI 15.7 kg/m2), without ascites and with healed ulcerations. The condition was consistent with kwashiorkor, a complication to malnutrition rarely seen in AN.

Non-alcoholic fatty liver disease among adult survivors of severe acute malnutrition

OBJECTIVE: To investigate whether malnutrition survivors had more liver fat than controls and whether marasmus survivors (Ms) had more liver fat than kwashiorkor survivors (Ks). SUBJECTS AND METHODS: We traced 726 of 1336 adults admitted to hospital as infants with a diagnosis of severe acute malnutrition. We used birthweight (BW) from hospital records and measured anthropometry, body composition (DEXA) and liver fat using single, crosssectional computed tomography (CT) scanning at T12/L1 vertebrae. Data were analysed using multivariate line arregression. RESULTS: We studied 45 Ms, 43 Ks and 84 age-, gender and body mass index (BMI)-matched controls (age 29.0 ±8.4 years, BMI 23.5 ± 5.0 kg/m2). Using LS ratio, malnutrition survivors had less liver fat than controls (1.3± 0.2 vs 1.2 ± 0.9, p = 0.03). Marasmus survivors had lower BW than Ks (-0.51 kg; p = 0.02), were younger (p =0.02), had smaller waists (p = 0.03), were thinner (p =0.01) and had less body fat (p = 0.05) compared to Ks.Marasmus survivors had more liver fat than Ks after adjusting for age, gender and BW (â = -2.62, SE = 1.23; p= 0.03). Lower BW infants had less liver fat after adjusting for diagnosis (â = -1.51, SE = 0.76; p = 0.04). CONCLUSION: Fatty liver occurs at lower BMI in Ms compared with Ks; this difference is likely due to both prenatal and postnatal factors acting independently. While further studies are needed to understand the mechanisms involved, our data suggest the need to monitor infants exposed to severe acute malnutrition beyond the acute episode.

A kwashiorkor case due to the use of an exclusive rice milk diet to treat atopic dermatitis.

Although several cases of severe hypoalbuminemia resulting from rice milk have been described in the past, today the use of rice milk without nutritional counseling to treat eczema is still a continuing, poor practice. We describe a kwashiorkor case in an infant with severe eczema exclusively fed with rice milk. It is well documented that rice milk is not a sufficient protein source. Moreover, only a small portion of eczema is triggered by food allergy. In conclusion this case raises the importance of managing dietary changes facing food allergies with responsibility for specialized consensus among pediatricians, nutritionists, endocrinologists and allergists all of them specialist professionals.

Misdiagnosed food allergy resulting in severe malnutrition in an infant.

As food allergies become increasingly prevalent and testing methods to identify "food allergy" increase in number, the importance of careful diagnosis has become even more critical. Misdiagnosis of food allergy and inappropriate use of unproven testing modalities may lead to a harmful food-elimination diet. This case is an example of an infant who was placed on an overly restrictive elimination diet at the recommendation of her health care providers, resulting in kwashiorkor and acquired acrodermatitis enteropathica.

Acquired protein energy malnutrition in glutaric acidemia.

We report a case of acquired protein energy malnutrition with associated zinc deficiency in an 18-month-old boy with type 1 glutaric acidemia. Physical examination findings included generalized nonpitting edema, widespread desquamative plaques, and sparse hair with a reddish tinge. Laboratory abnormalities included low levels of zinc, albumin, alkaline phosphatase, and iron. A review of skin manifestations of nutritional deficiencies, specifically kwashiorkor, is presented, as well as the relatively new entity called acrodermatitis dysmetabolica.

Acute inpatient presentation of kwashiorkor: not just a diagnosis of the developing world.

We present the case of an infant with presumed Stevens-Johnson syndrome. Through a history, physical, and histopathology, we were able to diagnose the patient with kwashiorkor. Physicians should be aware of this disorder, which is commonly thought of as a developing world problem, because it is increasing in incidence in industrialized nations because of changing dietary habits.

Under-five protein energy malnutrition admitted at the University of Nigeria Teaching Hospital, Enugu: a 10 year retrospective review.

OBJECTIVE: To determine the prevalence, risk factors, co-morbidities and case fatality rates of Protein Energy Malnutrition (PEM) admissions at the paediatric ward of the University of Nigeria Teaching Hospital Enugu, South-east Nigeria over a 10 year period. DESIGN: A retrospective study using case Notes, admission and mortality registers retrieved from the Hospital's Medical Records Department. SUBJECTS: All children aged 0 to 59 months admitted into the hospital on account of PEM between 1996 and 2005. RESULTS: A total of 212 children with PEM were admitted during the period under review comprising of 127 (59.9%) males and 85 (40.1%) females. The most common age groups with PEM were 6 to 12 months (55.7%) and 13 to 24 months (36.8%). Marasmus (34.9%) was the most common form of PEM noted in this review. Diarrhea and malaria were the most common associated co-morbidities. Majority (64.9%) of the patients were from the lower socio-economic class. The overall case fatality rate was 40.1% which was slightly higher among males (50.9%). Mortality in those with marasmic-kwashiokor and in the unclassified group was 53.3% and 54.5% respectively. CONCLUSION: Most of the admissions and case fatality were noted in those aged 6 to 24 months which coincides with the weaning period. Marasmic-kwashiokor is associated with higher case fatality rate than other forms of PEM. We suggest strengthening of the infant feeding practices by promoting exclusive breastfeeding for the first six months of life, followed by appropriate weaning with continued breast feeding. Under-five children should be screened for PEM at the community level for early diagnosis and prompt management as a way of reducing the high mortality associated with admitted severe cases.