Porth's Essentials of Pathophysiology, 4e

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Disorders of Nutritional Status

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a starchy gruel feeding. Kwashiorkor is a more severe form of malnutrition than marasmus. Unlike maras- mus, severe protein deficiency is associated with severe loss of the visceral protein compartment with a resul- tant hypoalbuminemia that gives rise to generalized or dependent edema. The child with kwashiorkor usually presents with edema, desquamating skin, discolored hair, anorexia, and extreme apathy (Fig. 10-4). There are “flaky paint” lesions of the skin on the face (Fig.10-5), extremities, and perineum and the hair becomes a sandy or reddish color, with linear depigmentation (flag sign). 43 There is generalized growth failure and muscle wast- ing as in marasmus, but subcutaneous fat is normal, since calorie intake is adequate. Other manifestations include skin lesions, hepatomegaly and distended abdo- men, cold extremities, and decreased cardiac output and tachycardia. Marasmus-kwashiorkor is an advanced protein-calo- rie deficit together with increased protein requirement or loss. This results in a rapid decrease in anthropometric

Hair changes

Flag sign

Growth failure

measurements with obvious edema and wasting and loss of organ mass. One essential aspect of severe pro- tein-energy malnutrition is fatty degeneration of such diverse organs as the heart and liver. This degeneration causes subclinical and overt cardiac dysfunction, espe- cially when malnutrition is accompanied by edema. A second injurious aspect is the loss of subcutaneous fat, which markedly reduces the body’s capacity for temperature regulation and water storage. As a conse- quence, malnourished children become dehydrated and hypothermic more quickly and more severely than nor- mally nourished children. 40 Most children with severe protein-energy malnutrition have asymptomatic infec- tions because their immune systems fail to respond appropriately. Malnutrition inTrauma and Illness In industrialized societies, protein-energy malnutrition most often occurs secondary to trauma or illness. Kwashiorkor-like secondary protein-energy malnutri- tion occurs most commonly in association with hyper- metabolic acute illnesses, such as trauma, burns, and sepsis. 44 Marasmus-like secondary protein-energy mal- nutrition typically results from chronic illnesses such as chronic obstructive pulmonary disease (COPD), congestive heart failure, cancer, and HIV infection. Approximately half of all persons with cancer experience FIGURE 10-5. Infant with symptoms indicative of Kawashiokor, a dietary protein deficiency, as well as a vitamin B deficiency. (From the Centers for Disease Control and Prevention Public Health Image Library. No. 6180.)

Apathy, irritability

Muscle wasting

Fatty liver

Villous atrophy of small intestine, diarrhea

Depigmentation of skin

Dermatoses

Edema (hypoalbuminemia)

FIGURE 10-4. Clinical manifestations of Kwashiorkor.