University of Alabama at Birmingham

2001 Case #6

Universidad Peruana Cayetano Heredia
The following case was seen on the Pediatric Service of the Regional Hospital of Cusco by course participants during the course field trip to Cusco. Cusco is the oldest continuously inhabited city in the New World and is at an elevation of 3,400 meters (10,500 feet) in a valley in the Andean highlands. Many of the inhabitants are descendants of the Incas and only speak Quechua, Peru's other official (and original) language aside from Spanish.
Image for 02/26/01History: 23 month old male child with a 10 day history of vomiting, diarrhea, and progressive edema of the face and both upper & lower extremities. Diffuse skin rash (see photo) of uncertain duration with apparent intense pruritus. No fever. No contacts with infectious diseases. Increasingly miserable and apathetic over last several months. Breast fed until 5 months ago. Given BCG, DPT, polio at birth but no other vaccines since.

Epidemiology: From Sicuani, a small rural agricultural settlement in the Andean highlands 6 hours from Cusco and at similar elevation (3400 meters). One of six family members living in a single room adobe dwelling with multiple animals.

Physical Examination: Afebrile. On admission 10 days before seen by participants of the Gorgas Course, symmetrical edema of face, and of both lower and upper extremities without anasarca. Edema now mostly resolved. Body habitus and skin lesions (similar lesions on lower extremity and trunk as well) as shown in photo. No murmurs, no organomegaly, no mucosal lesions.

Labs: Hct 30. WBC 9.8. BUN/Cr 7/0.4. Urinalysis - no cells, casts, or protein. Serum protein 4.5 mg/dl. Serum albumin 2.0 mg/dl. Skin scrapings - nothing seen by direct microscopy.






University of Alabama at Birmingham

2001 Case #6
Diagnosis and Discussion

Universidad Peruana Cayetano Heredia
Diagnosis: Moderately severe Kwashiorkor (protein/energy malnutrition), also called edematous malnutrition. Possible scabies.
Discussion: In this child, weight for age was calculated at 72% of the median WHO standard indicative of moderate malnutrition. Weight for height was 83% and height for age 91%, indicative of mild malnutrition.

This child presents with a classical clinical presentation for edematous malnutrition and a classical epidemiologic history for the Andean highlands. Breastfeeding stopped several months earlier when another child was born. His diet then consisted primarily of potatoes and corn, the 2 crops that grow well at this altitude but which make for a diet high in carbohydrates but without any protein. Clinically, children with edematous malnutrition have swelling of the face, legs and arms, an apathetic and miserable affect, moon face, thin hair with weak roots, wasted weak muscles and often an enlarged liver. Non-specific diarrhea and vomiting perhaps due to GI damage is common. The edema may convince parents that the child is plump and well.

Typical skin lesions include atrophy, patches of erythema, patches of either hyper or hypopigmentation and skin breakdown with ulceration; all found in our patient. The pruritic nature of some areas of the skin call into question the issue of scabies which is very common in this environment due the amount of infrequently washed clothing worn in large amounts in this harshly cold environment. As scabies mites are most often difficult to detect even with proper skin scraping and microscopy, scabies remains a clinical diagnosis in most cases and in Peru is most often treated with benzyl benzoate (inexpensive) or permethrin topically.

Feeding should be started gradually and is divided into an initial and rehabilitation phases. Malnourished children do not tolerate the usual amounts of dietary protein or sodium. Too rapid initiation of feeding will lead to overhydration, severe metabolic imbalance and congestive heart failure, which if it occurs is an emergency. This patient was started on 0.5 gm protein/kg/day, with 80 kcal/kg/day and 80 kcal/100ml of fluid and then advanced in 2 steps to 1.5 gm/protein/kg/day, with 120 kcal/kg/day and 120 kcal/100 ml of fluid once he was hungry and eating. Protein is provided in powder form and is derived from soy, milk, and egg protein.

In addition, it is mandatory to give Vitamin A immediately upon admission to avoid blindness. The diet also contains Mg sulfate, Cu sulfate, Zn sulfate.

The prognosis for this child in the environment to which he is returning is extremely poor. The parents will likely feel that the hospitalization has been detrimental when the plump fat child is returning as a much skinnier appearing child. Despite free government supplied vaccines in most of the neighboring larger communities to their village, the uptake and interest in rural areas has been poor due to cultural factors which do not incorporate the injection of foreign materials into the body into the overall belief system.