Marasmic kwashiorkor

Symptoms of kwashiorkor are apathy, muscular wasting, and edema. Both the hair and the skin lose their pigmentation. The skin becomes scaly and there is diarrhea and anemia, and permanent blindness can result from this condition. Marasmus is another condition of a wasting away of the body tissues from the lack of calories as well as protein in the diet. In marasmus the child is fretful rather than apathetic and is skinny rather than swollen with edema. Aside from contrasting symptoms between the two diseases, there may be converging symptoms which would be described as marasmic kwashiorkor. 

Protein-energy malnutrition in children can therefore be classified by both the deficit in weight compared with what would be expected for age and also the presence or absence of oedema, as shown in Table 8.2. The most severely affected group, and therefore the priority group for intervention, are those suffering from marasmic kwashiorkor - they are both severely undernourished and also oedematous. 

Figure 8.5 Stunting of growth in kwashiorkor, marasmus and marasmic kwashiorkor.

Marasmic Kwashiorkor Nutritional Dwarfing or Growth Failure Protein-Energy Malnutrition (PEM) in Adults Signs of Protein-Energy Malnutrition Indicators of Protein-Energy Malnutrition in Communities... 

Depending upon the nature and extent of the deficiency, there is at one extreme Kwashiorkor, or severe deficiency of protein and at the other, marasmus, or severe deficiency of energy. In between are the combination disorders such as marasmic kwashiorkor and nutritional dwarfing. More than likely, deficiencies of certain minerals and vitamins accompany all of these disorders, except that the problems due to severe deficiencies of protein or energy overshadow the other problems. A discussion of the characteristics of each type of PEM follows. 

Marasmic Kwashiorkor. This condition is found in many situations where children are fed diluted gruels after weaning. It is characterized by a combination of disorders which accompany both marasmus and kwashiorkor. Today, the tendency is to use the generalized term, protein-energy malnutrition, to describe this condition. 

Marasmic kwashiorkor—Patients who show features of both marasmus and kwashiorkor are usually given the general diagnosis of protein-energy malnutrition. 

Marasmus is characterized by the loss of lean tissue and subcutaneous fat, causing characteristic wrinkling of the skin. It can be difficult to differentiate from dehydration. It is possible to present with a combination of the two, called marasmic kwashiorkor. 

Results from two different groups of children reveal that the serum immunoglobulin levels in children with marasmus are not significantly different from those with kwashiorkor. Sixteen marasmic infants free from all signs of apparent kwashiorkor but all having gastrointestinal disturbances or respiratory infections had immunoglobulin levels as fol-... 

Although glutathione is specifically decreased in kwashiorkor, blood levels of selenium-dependent glutathione peroxidase (a scavenger of peroxides) and vitamins A, C, and E (all members of the antioxidant machinery) are lower in both kwashiorkor and marasmus (Ashour et al., 1999). Why then are marasmic children, also deficient in some antioxidants, spared the oxidative stress Does a weakened antioxidant defense manifest as a serious threat only in the presence of pro-oxidant activities of the type encountered in kwashiorkor What is a possible trigger for the increase in free radicals, and how might this account for some of the phenotypic alterations in kwashiorkor ... 

Unlike marasmic or well-nourished children, those with kwashiorkor have low transferrin levels and detectable free iron in the plasma (Sive et al., 1996). Uncomplexed iron is extremely toxic due to its ability to generate free radicals by the Haber-Weiss and Fenton reactions.The onslaught of opportunistic infections in the malnourished also elicits production of free radicals and accentuates the oxidative stress. 

Free radicals through lipid peroxidation can cause membrane damage, induce electrolyte imbalance and edema. Indeed, children with kwashiorkor display low levels of polyunsaturated fatty acids (e.g., linoleic acid) in the erythrocyte membrane compared to the marasmic children, presumably due to increased lipid peroxidation (Leichsenring et al., 1995). Interestingly, cysteinyl leukotrienes, which can cause edema by altering capillary permeability, are also enhanced in those with kwashiorkor but not marasmic children (Mayatepek et al., 1993). 

In Cape Town the zinc concentration in the liver but not in the brain, heart, or muscle of children dying from kwashiorkor was significantly lower than normal. Plasma zinc levels were also low in marasmic infants. 

Applying this technique to malnourished children, it was demonstrated, not surprisin y, that muscle mass was severely reduced [350]. There was a greater reduction in muscle mass per kg body weight in kwashiorkor than marasmic infants even after the loss of oedema in the former group. It was also apparent that the creatinine excretion underestimated the degree of muscle mass deple-... 

The energy and protein requirements like those of any other nutrient vary considerably from individual to individual and in India no difference was found in the diet of children who developed kwashiorkor and those who became marasmic. Consequently it has been suggested that the form of protein-energy malnutrition seen in children may be determined as much by their individual requirements and response to stress as to the amount and type of food that they consume. A child with a high protein and low energy requirement will tend to develop kwashiorkor and one with a low protein and high energy requirement will tend to become marasmic. 

Production of l3nnphocyte mediators in PEM has not been well studied thus far Schlesinger et al. (1977) noted diminished in vj tro interferon production by lymphocytes from marasmic children induced by Newcastle Disease Virus, while Chandra (1979) found similar changes in kwashiorkor. Other studies in animals have yielded conflicting results, however (Gautam et al., 1973 Kramer and Good Woodruff, 1970). 

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