Protein energy malnutrition differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Omodamola Aje B.Sc, M.D. [2]

Overview

Protein energy malnutrition must be differentiated from other diseases that cause failure to thrive, edema, wasting recurrent infections, skin and hair changes. It is important to also differentiate kwashiorkor from marasmus as the two diseases are caused by protein-energy malnutrition and share similar features such as, weight loss, muscle wasting, low blood glucose levels and growth retardation.

Differentiating Protein Energy Malnutrition From Other Diseases

Differentiating kwashiorkor from marasmus

Kwashiorkor must be differentiated from marasmus as the two diseases are caused by protein-energy malnutrition and share similar features such as, weight loss, muscle wasting, low blood glucose levels and growth retardation. The followwing table differentiates between the two:

Distinguishing Features	Kwashiorkor	Marasmus
Cause	Deficiency of protein in the diet of child	Deficiency of protein as well as energy nutrients (that is carbohydrates and fats) in the diet
Age	Occurs in children in the age group 1-5 years	Typically occurs in children below the age of 1 year
Association	More common in villages where there is small gap period between successive pregnancies	More common in towns and cities where breast-feeding in discontinued quite early
Edema	Presence of edema	Absence of edema
Muscles	Wasting of muscles	Wasting of muscles is quite evident. The child is reduced to skin and bones
Skin changes	Dermatitis and hyperpigmentation noticed	Dry and atrophic skin but no changes in color
Serum cortisol	Decreased/Normal	Increased
Fasting blood glucose	Decreased	Decreased
Growth retardation	Mildly retarded in growth	Severely retarded in growth
Facial appearance	Moon-like face	Sunken eyes, maxillary prominence, loss of buccal fat pad
Abdomen	Protuded	Shrunken
Vitamin deficiency	Present	Present
Weight	60-80% of normal weight for age	<60% of normal weight for age

Differential diagnosis of edema and wasting

Disease	Cause	Age(years)	Presentation	Prevention	Workup	Prognosis	Treatment
Kwashiorkor	Deficiency of protein-rich foods like meat and poultry in diet Early weaning	< 1	Apathy Lethargy Irritability Cachexia Flag sign of hair Hyperkeratosis / dermatitis of skin Anemia Congestive heart failure Hypoalbuminemia Chronic fatty liver Hepatomegaly Edema	Balanced diet of carbohydrates, protein and fat	Complete blood count (CBC) Arterial blood gas (ABG) Blood urea nitrogen to creatnine ratio Serum potassium Total protein Urinalysis	Prognosis is good if treated early Lipiduria and ketonuria portend a poorer prognosis	Caloric replacement Protein replacement Vitamin and mineral supplementation Antibiotics if infections are present Plasma expanders and oral rehydration solution (ORS), if shock is present Lactase if lactose intolerant
Marasmus	Protein energy malnutrition (PEM) Hospitalized patients with malignancy Cystic fibrosis Neurologic diseases Genetic diseases End stage renal diseases	< 5	Hypo / hyperthermia Dehydration Skin pallor Anemia Corneal lesions (due to vitamin A deficiency) Decreased peripheral pulses Confusion	Balanced diet Prophylactic antibiotics	Blood glucose Peripheral blood smear Hemoglobin Urinalysis and culture Stool exam Albumin tests Electrolyte level	: Prognosis is good if underlying medical illness is treated Bacterial infection and renal failure may portend a poorer prognosis	: Blood glucose control Prevent hypothermia Prompt correction of dehydration Early detection and correction of electrolyte imbalance Active control of infections Screening and stabilization of micronutrient deficiencies Feeding for initial stabilization Nutritional support to support normal growth Psychological support, care and stimulation Careful follow-up of cases upon discharge
Protein losing enteropathy	Infectious agents Immune related diseases Neoplasms affecting the GI tract	All age groups	Generalized peripheral edema Gastrointestinal disorders Abdominal pain Diarrhea Malnutrition Weight loss	Avoidance of infections and other diseases associated with protein losing enteropathy	Measurement of albumin/globulin levels Presence of α1-antitrypsin in stool samples Measuremnent of vitamins A, D, E and K	Prognosis largely depends on the underlying disease If it is potentially curable, prognosis improves considerably	Antiparasitic agents ACE inhibitors and diuretics Surgical interventions may be required to resect neoplasms Low-fat diets supplemented with medium-chain triglycerides
Anasarca	Protein energy malnutrition Increased hydrostatic pressure Reduced oncotic pressure Lymphatic obstruction Some cancers	1-4	Generalized edema of body tissues with profound subcutaneous swelling	Healthy balanced diet in children Treatment of underlying heart problems Treatment of cancers	CBC ABG Brain natriuretic peptide (BNP) BUN:Cr Serum potassium Total protein Urinalysis	Good prognosis if the underlying cause is identified and treated early	Treatment is targeted at the underlying cause Diuretics if due to fluid overload Albumin infusion to correct hypoproteinemia
HIV wasting syndrome	HIV infection	All age groups	>10% total body weight loss Severe diarrhea Chronic weakness Fever lasting for more than three to four weeks HIV infection	Use of HAART	Nutritional assessment Serial measurements of weight Body mass index (BMI) Total body water and fat Sequential anthropometry (mid arm circumference, triceps, skinfold thickness) to predict prognosis	Prognosis is good with the use of highly active anti-retroviral therapy (HAART)	HAART Megestrol acetate Marijuana (in some states) Dronabinol Somatropin
Chronic pancreatitis	Tumors or stones Toxic metabolites Necrosis Fibrosis Oxidative stress Ischemia Alcohol consumption Autoimmune disorders	30 to 40 years	Epigastric abdominal pain Nausea Vomiting Decreased appetite Exocrine and endocrine dysfunction Weight loss Protein deficiency Diarrhea and steatorrhoea Secondary diabetes mellitus	Avoiding alcohol can reduce the risk for the development of chronic pancreatitis	Pancreatic enzymes Blood sugar Stool analysis for presence of enzymes and fat Computerized tomography X-rays Magnetic resonance cholangiopancreatography Transabdominal ultrasound	Patients who get medical care early have a good prognosis Increased risk of pancreatic cancer	Ibuprofen and acetaminophen along with antioxidants Surgical options are considered if medical options fail
Pediatric nephrotic syndrome	Glomerular lesions such as minimal change nephrotic syndrome Secondary nephrotic syndromes Genetic abnormalities such as infantile nephrotic syndromes Infections Drugs	<16years	Nephrotic-range proteinuria Edema Hyperlipidemia Hypoalbuminemia	Avoid infections and drugs that may predispose to nephrotic syndrome	Urinalysis Urine protein quantification (by first-morning urine protein / creatinine or 24-hour urine protein) Serum albumin Lipid panel	Prognosis depends on whether the nephrotic syndrome is steroid responsive or steroid resistant	Corticosteroids Diuretics Antihypertensive agents Alkylating agents Calcineurin inhibitors Home monitoring of urine protein and fluid status
Portal cirrhosis	Hepatitis C (26%) Alcoholic liver disease (21%) Hepatitis C plus alcoholic liver disease (15%) Cryptogenic causes (18%) - Many cases actually are due to NAFLD Hepatitis B - May be coincident with hepatitis D (15%) Miscellaneous (5%)	5th - 6th decade of life	Hepatomegaly Abdominal pain Ascites Abdominal distension Bulging flanks Shifting dullness Puddle sign	Avoid alcohol Treatment and vaccination against hepatitis Good diet and exercise	CBC Albumin Culture Total protein Serum ascites albumin gradient Ammonia level	Prognosis is poor	Prednisone and azathioprine - For autoimmune hepatitis Interferon and other antiviral agents - For hepatitis B and C Phlebotomy - For hemochromatosis Ursodeoxycholic acid - For primary biliary cirrhosis Trientine and zinc - For Wilson disease Liver transplantation

Table adapted from CDC Pinkbook.