General Malnutrition

Concurrent colonization by Gram-negative bacilli occurs in some patients with failure of the gastric acid barrier, suggesting additional deficiencies of host defense abnormal oral flora, malnutrition, general illness, or diseases or medication interfering with intestinal peristalsis and clearance. This type of microflora is also seen in 10-30% of patients on acid inhibitors, for which mucosal injury and functional changes related to peptic ulcer and reflux disease may be responsible. 

Severe malnutrition generally affects the T cell rather than the B cell compartment. The basis for immune impairment of both children and experimental animals may well be atrophy of the thymus. The thymus is the slowest organ to recover following nutritional repletion (McFarlane, 1977). Severe malnu-... 

Generally, nephrotoxicity is not a problem. Some cephalosporins, especially those with the 3-methylthiotetrazole side chain, such as moxalactam (48), show a tendency to promote bleeding. This appears to be due to a reduction in the synthesis of prothrombin and can be a problem especially in elderly patients, patients with renal insufficiency, or patients suffering from malnutrition (219). The same side chain seems to promote a disulfiramlike reaction in patients consuming alcohol following a cephalosporin dose (80,219). 

In tropical sprue, gluten does not appear to play much part in relatively early cases, such as those studied in Hong Kong. There is evidence, however, that patients with chronic sprue of many years duration may show some improvement on a gluten-free diet (C2). This may be a secondary phenomenon, due to general reduction of the enzymes in the small intestinal mucosa other mucosal enzymes have been shown to be reduced or ineffective in these patients. The important question is whether such patients will still react to gluten when the mucous membrane is brought back to normal by appropriate therapy, if this can be achieved. The rehabilitation of a malnutritional state induced over a period of many years is an extremely complex problem. 

It is generally accepted that malnutrition decreases the effectiveness of the immune system so that it increases the incidence of infections. Thus famine and infections are always considered together since it is assumed that the former exacerbate the latter. The influenza pandemic in 1918-19 in Europe led to the deaths of more than 20 million people. Poor nutrition caused by the First World War may well have impaired the immune system in many people, thus contributing to the large number of deaths. This topic is discussed in Chapter 18. 

The symptoms of pantothenic acid deficiency have not been clinically described. Since pantothenic acid is a ubiquitous vitamin, isolated deficiency is unlikely. However, marginal deficiency may exist in persons with general malnutrition. 

TNF-a is identical to cachetin, a protein that suppresses completely the lipoprotein lipase of adipose tissue and is believed to be responsible for cachexia, a condition of general ill health, malnutrition, weight loss, and wasting of muscle that accompanies cancer and other chronic diseases. Nevertheless, TNF-a may be overproduced in obesity as well. It has been suggested that abnormal production of TNF-a may induce cachexia while abnormal action of the cytokine may cause obesity.233 Some TNF receptors have "death domains" and trigger apoptosis, while other receptors promote proliferation and differentiation via transcription factor NF-kB.242... 

In Berlin in 1948, there were still incidences of malnutrition. Because of this, there were patients who suffered fatal poisoning from the generally safe, local anaestetic drug procaine. This became my impetus to study the esterase that hydrolysed procaine (9). When invited to Philadelphia, I continued these studies with the superior equipment there available to me. I found that the procaine-splitting esterase was butyrylcholinesterase, then called pseudo- or plasma-cholinesterase, and I explored a method using UV-spectrophotometry which elegantly and precisely indicated the esterase activity (10). 

As pointed out by Anderson et al. (15), starvation, malnutrition, and protein deficiency may all cause differences in drug disposition and thereby differences of drug action. Even relatively minor food deficiencies as observed in Berlin after the second World War (16) caused some unusual reactions, e.g., death from injection of the old and generally safe local anesthetic drug procaine (17). 

The tools for nutritional assessment include medical history and screening aides, physical examination and anthropometric measurements, biochemical assessment, and tests of immune function. A general health assessment and medical history are required to rule out causes of secondary malnutrition such as poor oral health, chronic illness, disease, and medication. Malnutrition is influenced by lifestyle, which includes alcohol usage in adults, food preference, eating habits, social interactions, and economic status. Various screening tools, such as the DETERMINE checklist (White et al., 1991), are available to assess the risk of malnutrition. 

Current evidence suggests that chronic alcoholic patients can be given paracetamol in normal therapeutic doses, as unless they have other risk factors such as malnutrition, their risk of developing severe hepatotoxi-city is no greater than that of the general population. 

Dietary deficiency. Folate deficiency is extremely common in the setting of general malnutrition in developing countries and is a particular problem in childhood. In Western countries folate deficiency occurs in alcoholics, some slimming diets, the elderly, the infirm and psychiatric patients. 

Studies in underdeveloped countries have shown that xerophthalmia results in the blindness of a quarter million children per year in Asia alone. Attempts have been made to detect a relationship between the occurrences of xerophthalmia and respiratory or diarrheal infections. Some studies have found an association others have not, Generally, the populations suffering from malnutrition and chronic diarrheal iiifections are those afflicted with xerophthalmia. 

The deficiency results from general malnutrition (lack of meat), as well as from the wheat-based diet. The symptoms include lack of sexual maturation and small stature. Supplementation of affected young adults with zinc provokes the growth... 

Common adverse effects of meglumine antimonate are anorexia, nausea, vomiting, malaise, myalgia, headache, and lethargy. Muscle, bone, and joint pains have been described (SEDA-12, 710) (SEDA-13, 838) (20). Cardiac toxicity and electrocardiographic changes are dose-related. The general condition of the patient with visceral leishmaniasis probably plays a crucial role in these and other adverse effects. Malnutrition is common, the immune status often severely impaired, and patients are susceptible to intercurrent infections (SEDA-12, 710). 

Like oral iron, parenteral iron is used too widely. When iron is truly needed, oral administration is generally preferable (9). Intractable gastrointestinal intolerance to oral formulations, hyperemesis in pregnancy, very severe blood loss, and possibly ulcerative colitis are some of the few valid indications for parenteral iron. A low ironbinding capacity (for example due to prior saturating iron therapy or malnutrition), folic acid deficiency, and an allergic constitution predispose the patient to adverse reactions to parenteral iron. Iron injections have been reported to provoke hemolytic anemia in cases of paroxysmal nocturnal hemoglobinuria. 

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