University of Alabama at Birmingham 2010 Case #9 Universidad Peruana Cayetano Heredia

The Gorgas Course in Clinical Tropical Medicine spent its last week with a 4-day field trip to Iquitos on the banks of the Amazon River.  Iquitos, with a population of approximately 500,000, is the largest city in the world that is reachable only by air and by river.  The nearest road ends over 400 km away.

Publishing a case report every week for 9 consecutive weeks would not be possible without the assistance of an extremely dedicated group of people.  We would like to thank in particular: Dr. Carlos Seas, Clinical Rounds Coordinator for the Gorgas Courses for case selection, coordination of case summaries and images; and Adam Plier of the Gorgas Center for Geographic Medicine of the UAB Division of Infectious Diseases for all publishing on the Gorgas Course web site.

We hope you have enjoyed this year’s cases.  In August 2010 we will be running the 2-week Gorgas Expert Course (places still available) and will present a couple more cases during that time.  We will also be in touch in January 2011 at the beginning of next year’s case series.
The following patient was seen by Gorgas Course participants on the Pediatric Ward of the Iquitos Hospital.

Image ABCDE for 04/12/2010History:  22 month old female with the onset 2 months prior to admission of fever, erythematous macules on both upper and lower limbs, vomiting, diarrhea, and edema that progressively involved lower limbs, upper limbs and face.  The edema improved with furosemide.  A week later, the macules turned dark (“black”) which did not improve with local herbal remedies.  By 2 weeks before admission the dark lesions involved all of the body, including the face.  Blistering lesions developed that broke leaving denuded areas.  She has had recurrent diarrhea since she was 2 months old, and also many respiratory infections.  Two months ago she passed two Ascaris worms.

Epidemiology:  Born and lives in a rural village on the Amazon River,two hours from the nearest road.  No potable water and no drainage, latrinesor sewers are present.  Vaccines are up to date for her age.  No historyof malaria and no contact with known TB cases.  Breast-fed until age 17months with solid meals three times per day starting at 9 months.

Physical Examination:  (on admission) Afebrile. HR:116, RR:40, BP70/50 mmHg.  Height: 80 cm, Weight: 8.5 Kg.  Poor general condition,dehydrated, pale, generalized edema.  Brittle hair.  Dark hyper-pigmentedskin lesions involving most of the skin, with some small blisters and some denudedareas [Images A-E].  No lymphadenopathy.  Head: sunkeneyes, palpebral edema, dry oral mucosa.  Chest: lungs clear.  Heartsounds of decreased intensity, no murmurs.  Abdomen: soft, distended, tympanicto percussion, with normal bowel sounds, no organomegaly.

Laboratory Results:  Hematocrit 25%.  WBC: 11900 (no bands,82 neutrophils, 18 lymphocytes).  Platelets: 90000.  Glucose: 73 mg/dL.  Creatinine:0.7 mg/dL.





Diagnosis: Severe Kwashiorkor (protein/energy malnutrition), also called edematous malnutrition.
Discussion:  In this child, weight for age was calculated at below the 3rd percentile (WHO standard curves), indicative of severe malnutrition.  Height for age was between the 10-25th percentiles.  The weight is unreliable due to the edematous condition.  This is the first child, born at home, for the mother who was 13 years old at the time.  The mother left school to take care of the baby.

This child presents with a classical clinical presentation for edematous malnutrition and a classical epidemiologic history for the jungle.  Newborns are usually breast-fed but also receive a beverage made from water with mashed boiled banana, which satisfies the child, but who then receives less breast milk.  Bottle-feeding increases the risk of bacterial contamination and diarrhea, as in our patient, who has had recurrent diarrhea since the age of 2 months.  Solid feedings began when she was 9 months old and consisted primarily of rice, yucca, banana and noodles – the crops that grow well in this area 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 fatty liver.  Besides for infectious diarrhea, non-specific diarrhea and vomiting 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 hypo-pigmentation and skin breakdown with denuded areas and positive Nikolsky sign; all found in our patient.  Differential diagnosis of these pellagroid lesions should include drug-induced photodermatitis, lesions due to different nutritional deficits, and enteropathic acrodermatitis due to zinc deficiency, which produces vesiculobullous lesions, crusts and psoriasiform plaques.

Feeding should be started gradually and is divided into an initial and a rehabilitation phase.  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 approximately 0.5 gm protein/kg/day, with 75 kcal/kg/day and 126 kcal/100ml of fluid divided into six feedings per day via nasogastric tube.  In the refeeding formula, protein is provided in powder form and is derived from milk and cornstarch, along with oil and sugar.

In addition, it is mandatory to start Vitamin A 100,000 IU/d x 2d immediately upon admission to avoid blindness, along with other lipid-soluble vitamins like Vitamins D and K.  The diet also contains Mg sulfate, Cu sulfate, and Zn sulfate.  KCl (Kalium) 1 mL in each meal of refeeding formula is also necessary.  The child should be kept warm under a heating lamp.  Malnourished children should be presumed septic and in this case Ceftriaxone 425 mg IV /12h (100 mg/Kg/d) was administered.

The prognosis for this child in the environment to which she 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.  She will be subjected to environmental conditions (lack of potable water and sewage) that predispose her to infectious diarrhea and enteric parasitoses with their consequences of malnutrition, anemia, and growth and developmental retardation.  Malnutrition in the jungle has an educational problem as an important factor.  People from the communities, especially women, should be taught about adequate feeding practices for the newborn, infant and children.