Protein energy malnutrition differential diagnosis

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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 belong to the protein energy malnutrition.

Differentiating Protein energy malnutrition from other Diseases

Differentiating kwashiorkor from marasmus

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	Elderly man face
Abdomen	Protuded	Shrunken
Vitamin deficiency	Present	Present
Weight	60-80% of normal weight for age	<60% of normal weight for age

Differential diagnosis of childhood malnutrition

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 Cachexic 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	CBC ABG BUN:Cr 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 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 distal pulses Confusion	Balanced diet. Prophylactic antibiotics	Blood glucose Peripheral blood smear Hemoglobin Urinalysis and culture Stool exam Albumin tests Electrolyte level	: Prognosis good if underlying medical illness 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
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) Evaluate LBM, Total body water and fat Sequential anthropometry (mid arm circumference, triceps skinfold thickness) to predict prognosis	Prognosis is good with the use of HAART	HAART Megestrol acetate Marijuana (in some states) Dronabinol Somatropin
Congenital heart disease
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
Congenital nephrotic syndrome
Portal cirrhosis

Table adapted from CDC Pinkbook.