Case history
Case history #1
A 24-month-old girl presents with swelling of the hands and feet. The child lives in rural sub-Saharan Africa, where she eats a predominantly corn-based diet with her family. She was weaned off the breast 2 months earlier. She has had a reduced appetite for 10 days and has become more irritable over the last 5 days, with bilateral swelling noted on the dorsum of the feet. There is no history of haematuria, fever, or chronic medical illnesses. On examination, she has pitting oedema of the feet bilaterally. With sustained, firm pressure, the imprint of the examiner's thumb is seen and an 8-mm depression is created. She has a dry, flaky rash on the lower extremities, which consists of hyper-pigmented patches that flake off to reveal hypo-pigmented patches with small ulcerations. Urine is negative for protein.
Case history #2
A 3-year-old boy has recently had measles infection, complicated by diarrhoea but no vomiting. He presents with a 1-week history of oedema initially of the feet, then legs, but now extending to the hands. He has sore eyes and photophobia. His weight for height has a z-score of -2.6. Examination shows desquamating dermatitis, particularly on the lower legs, where there is pitting oedema. He has 3 cm hepatomegaly and is apathetic. He will not open his eyes and has a corneal ulcer. He is hypothermic.
Other presentations
Breastfed children with kwashiorkor will often have an underlying illness; in HIV-endemic areas this is the most common cause. Older children presenting with wasting and kwashiorkor may also have underlying HIV and/or tuberculosis infection. HIV-affected children more frequently have oral pathology (particularly candidiasis), persistent moderate diarrhoea for >4 weeks, or chronic chest disease with bilateral basal crepitations and clubbing. Cerebral palsy is also a recognised cause for restricted diet and subsequent predisposition to kwashiorkor and marasmus.
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