The following symptomatology is evident in acute or chronic phase of Kwashiorkor:

General appearance: Kwashiorkor patients show apathy and lethargy as acute signs. They may appear with signs of easy irritability which are all attributed to low energy levels due to lack of protein. They are generally thin with cachexia due to the absence of muscle mass with defective protein synthesis.

Integumentary system: Hair may appear with different shades of light and dark bands referred to as the “flag sign”. The different hues in the hair represents the different periods of impaired nutrition. The skin will appear flaky due incompetent connective tissues formed from a defective protein synthesis process.

Cardiovascular and respiratory system: The heart may present with mild murmur due to micronutrient deficiency anemia or impending heart failure in the late stages. Pericardial effusion may present with severe PEM in children [7]. Breathing may be shallow due to metabolic acidosis.

Abdomen: The abdomen may be protuberant or enlarged due to ascites. The liquid damming in the abdominal cavity is due to the hypoalbuminemia effect on osmosis. Hepatomegaly may ensue with chronic fatty liver disease. Intestinal parasitism may not be infrequent with severe malnutrition.

Extremities: The limbs will generally convey weakness because of the lack of energy from proteins. Bipedal non-pitting edema may occur in the legs due to the osmotic imbalance.

• Malnutrition

  This suggests a decreased CYP1A2 activity in all categories of malnutrition. [ncbi.nlm.nih.gov]

  Protein malnutrition; Protein-calorie malnutrition; Malignant malnutrition Ashworth A. Nutrition, food security, and health. In: Kliegman RM, Stanton BF, St. Geme JW, Schor NF, eds. Nelson Textbook of Pediatrics. 20th ed. [nlm.nih.gov]

• Anemia

  Mediated by some complex mechanism, children suffering from sickle cell anemia are predisposed to PEM and Kwashiorkor. [symptoma.com]

  Initially, recovery was associated with rapid loss of weight and anemia and subsequently with weight gain and return to good health. [ncbi.nlm.nih.gov]

  It is characterized by marked hypoalbuminemia, anemia, edema, pot belly, depigmentation of the skin, loss of hair or change in hair color to red, and bulky stools containing undigested food. [medical-dictionary.thefreedictionary.com]

  […] of kwashiorkor : severe malnutrition chiefly affecting young children especially of impoverished regions that is characterized by failure to grow and develop, changes in the pigmentation of the skin and hair, edema, fatty degeneration of the liver, anemia [merriam-webster.com]

• Fatigue

  Until she began developing the symptoms of Kwashiorkor, including general fatigue, edema of the face and extremities, anemia, alopecia, and weight loss, she had been leading a normal life post-gastrectomy. [ncbi.nlm.nih.gov]

  Early symptoms include fatigue, irritability, and lethargy. As protein deprivation continues, one sees growth failure, loss of muscle mass, generalized swelling (edema), and decreased immunity. A large, protuberant belly is common. [amitahealth.adam.com]

  Symptoms include: Changes in skin pigment Decreased muscle mass Diarrhea Failure to gain weight and grow Fatigue Hair changes (change in color or texture) Increased and more severe infections due to damaged immune system Irritability Large belly that [nlm.nih.gov]

• Anorexia

  BACKGROUND: Customary blood protein markers for malnutrition are of limited value in the diagnosis of protein-energy malnutrition or anorexia nervosa in children and in the follow-up to refeeding in such children. [ncbi.nlm.nih.gov]

  Kwashiorkor is a form of severe protein–energy malnutrition characterized by edema, irritability, anorexia, ulcerating dermatoses, and an enlarged liver with fatty infiltrates. [osmosis.org]

  Children with kwashiorkor often develop irritability and anorexia. [en.wikipedia.org]

  Fad diets, inappropriate management of food allergies, and psychiatric diseases (eg, anorexia nervosa) can also lead to severe protein-energy malnutrition. [emedicine.medscape.com]

• Weight Loss

  The greater the weight loss, the lower the serum carnitine concentration amongst the kwashiorkor children (r 0.46; p 0.01). There was a linear relationship between serum free carnitine and hiolein oxidation (r 0.89; p 0.001). [ncbi.nlm.nih.gov]

  It leads to dehydration and weight loss. Starvation is a form of this disorder. [healthline.com]

• Diarrhea

  Systemic manifestations include peripheral edema, liver disease, neurologic changes, diarrhea, weight loss, and hypoalbuminemia. [ncbi.nlm.nih.gov]

  They may take a stool sample to rule out other issues related to diarrhea if diarrhea is a symptom. Your doctor may also test your urine or your blood to help identify a nutrition deficiency. [healthline.com]

  Pneumonia and diarrhea are almost always present. [dermatologyadvisor.com]

• Failure to Thrive

  Failure to thrive may not be a result of organ disease, physical abuse, or intentional neglect. We describe an infant who developed kwashiorkor with a high-fat, low-protein, nondairy coffee creamer diet. [ncbi.nlm.nih.gov]

  Failure to thrive (failure to put on height and weight) Loss of muscle mass Generalised swelling ( oedema ) Large protuberant belly (pot belly) Fatty liver Failing immune system so prone to infections and increased severity of normally mild infections [dermnetnz.org]

  A child with Kwashiorkor looking miserable and having brownish hair color which are signs of Kwashiorkor Signs and Symptoms of Kwashiorkor Growth retardation (failure to thrive) Edema (swelling of the body) Muscle wasting Apathy (loss of interest) and [jotscroll.com]

• Chronic Diarrhea

  Eventually, Kumpheak’s entire body became swollen, he developed a full-body rash, fever, chronic diarrhea and uncontrollable vomiting, all of which are signs of kwashiorkor. Kwashiorkor is a severe type of protein-deficiency malnutrition. [angkorhospital.org]

  The symptoms of marasmus include: weight loss dehydration chronic diarrhea stomach shrinkage You’re at an increased risk for marasmus if you live in a rural area where it’s difficult to get food or an area that has a food shortage. [healthline.com]

• Abdominal Distension

  History and Physical The clinical manifestations of kwashiorkor include the following: Peripheral pitting edema that begins in dependent regions and proceeds cranially Marked muscle atrophy Abdominal distension (with/without dilated bowel loops and hepatomegaly [ncbi.nlm.nih.gov]

• Recurrent Diarrhea

  Lack of exclusive breastfeeding may be an important cause of Kwashiorkor even before 1 year due to predisposition of the child to recurrent diarrhea and infections Kwashiorkor mostly occur in children that have been weaned suddenly or when weaning begins [jotscroll.com]

• Hepatomegaly

  The child presented at 10 months of age with decreased weight for height, rash, hepatomegaly, edema, hypoproteinemia, hypoalbuminemia, anemia, hypoglycemia, and evidence of hepatic sequestration of lipids. [ncbi.nlm.nih.gov]

  If hepatomegaly is found on physical exam, an abdominal ultrasound may be indicated. It is low in cost and doesn’t require exposure to radiation, and will provide an initial assessment of the hepatic anatomy. [cancertherapyadvisor.com]

  Exams and Tests The physical exam may show an enlarged liver ( hepatomegaly ) and general swelling. [health.ridgeviewmedical.org]

  Hepatomegaly may ensue with chronic fatty liver disease. Intestinal parasitism may not be infrequent with severe malnutrition. Extremities: The limbs will generally convey weakness because of the lack of energy from proteins. [symptoma.com]

• Dermatitis

  The presence of edema and "flaky paint" dermatitis should prompt a careful dietary investigation. [ncbi.nlm.nih.gov]

• Alopecia

  Cutaneous clues to the diagnosis of protein deficiency include the "flag sign," hypochromotrichia, alopecia, "crazy pavement" dermatosis, pallor, and glossitis. [ncbi.nlm.nih.gov]

  Chronic iron deficiency may cause diffuse hair loss (alopecia). [britannica.com]

• Dry, Brittle Hair

  brittle hair that falls out easily and may lose its colour failure to grow in height tiredness or irritability ridged or cracked nails Kwashiorkor can be fatal if it's left untreated for too long because children become very vulnerable to infections [nhs.uk]

Patients with Kwashiorkor are often subjected to these following tests:

• Complete blood count to determine state of anemia and inflammatory processes with infections.
• Arterial blood gases to determine extent of metabolic acidosis of the patient.
• BUN and Creatinine are accurate markers for the kidney’s health.
• Serum potassium determination guides management of hypokalemia.
• Total protein albumin and globulin determination to assess the levels of hypoalbuminemia and hypoglobulinemia.
• Urinalysis will show ketone bodies due to improper protein metabolism.

• Ketonuria

  ケトン尿 ketonuria ケトン尿症 ketosis ケトーシス ketosis prone diabetes ketosis prone diabetes ketotic hypoglycemia ケトン性低血糖症 kidney biopsy 腎生検 kidney failure 腎不全 kidney transplantation 腎移植 knee jerk 膝蓋腱反射 knee reflex 膝蓋腱反射 kwashiorkor クワシオルコル [jds.or.jp]

• Macrocytic Anemia

  Thus, anemia is usually present, most often hypochromic microcytic anemia, but a concurrent deficiency of folates may lead to a mixed microcytic-macrocytic anemia. [humpath.com]

The early intervention of fulfilling protein caloric deficiency in Kwashiorkor will greatly improve patient’s outlook. Dietary replacement therapy are arbitrarily dependent on the severity of the disease. Caloric replacement will usually start with carbohydrates and simple sugars until the patient is able to achieve adequate energy.

By then protein infusion may be necessary along with supplemental vitamins and minerals. Patients who underwent prolonged starvation may not be immediately infused with protein because it may trigger a Refeeding Syndrome (RS) which leads to the uncontrolled catabolic action of insulin [8]. Kwashiorkor patients with superimposed infections treated with antibiotics should be reevaluated for the kidney’s clearance of the drugs used because it is usually impaired in PEM [9].

Patients received in shock will benefit from the immediate transfusion with plasma expanders and fluids. Oral enzymatic replacement with lactase may be helpful in cases of lactose intolerance.

Kwashiorkor and other protein energy malnutrition is considered a metabolic emergency. Patients who get medical care early have a good outlook in the clinical course of the disease.

However, those treated at the later stage of the disease may still be alleviated but permanent conditions like mental and growth retardation may occur. Patients who demonstrated lipids and ketones in the urine may have a poorer prognosis with PEM [5].

Kwashiorkor and PEM carries a grim prognosis when it occurs in patients below 5 years of age and in elderly people beyond 55 years old [6].

Complications

The primary protein energy state in Kwashiorkor may give rise to these complications:

• Sepsis: The dermatologic manifestation of generalized ulceration may invite a host of pathogenic bacteria to the ailing body. Defective protein synthesis will impair antibody production which may hamper significantly the body’s immune response against invading microorganism.
• Coma: The state of continuous carbohydrate breakdown in the light of a limited supply of protein may lead to a system condition of metabolic acidosis. The rapid decline of pH and the increased acidity of the plasma may incapacitate the brain into a vegetative state of coma.
• Hypovolemic shock: The incompetent fatty liver in Kwashiorkor will decrease the albumin production and decrease the osmotic gradient in the intracellular spaces. Progressive dehydration due to an incompetent osmotic gradient within the vessels may lead to hypovolemic shock.
• Mental and physical disability: Uncontrolled metabolic imbalance that afforded chronic insults to the brain may result in a permanent mental retardation and physical incapacities.
• Death: The severe forms of these PEMs may culminate with liver failure, heart failure or renal failure that can eventually lead to death.

The basic etiology in Kwashiorkor is the limited or meager supply of food available in the community. This condition is greatly influenced by drought, famine, war, and political unrest which are common in some countries in Africa and Central America.

Kwashiorkor may also prevail in communities with no access to protein-rich foods like meat and poultry and are solely dependent on carbohydrates from grains and vegetables.

The incidence of Kwashiorkor in the US is relatively low but PEM is somewhat prevalent among hospitalized patients. The World Health Organization in 2000 announced that there at least 181.9 million children suffering from severe malnutrition especially in developing countries. Statistics in Central Asia and Eastern Africa reveal that approximately half of the children have some form of growth retardation due to protein energy malnutrition.

About 5 million children deaths in the developing countries are related to PEM and Kwashiorkor. Mortality rates in Kwashiorkor decrease with increasing age of its onset. The dark skinned races have more incidence of Kwashiorkor due to the relatively poor socio-economic situation in their country that affects dietary input.

Mediated by some complex mechanism, children suffering from sickle cell anemia are predisposed to PEM and Kwashiorkor [1].

Kwashiorkor as a protein energy malnutrition state in children happens with adequate carbohydrate nutrition but devoid of protein sources.

This condition will lower the body’s drive to produce its own visceral protein leading to poor energy supply. In Kwashiorkor, low protein substrates (raw materials) can lead to hypoalbuminemia that causes the extravasation of fluid to the extracellular space manifesting as edema.

Consequently, this low protein state may impair the production of B-lipoproteins that results in a fatty liver [2]. The inadequate production of transfer proteins may lead to micronutrient deficiency like zinc.

The concurrent zinc deficiency is implicated as the main cause of skin diseases like ulcerations in Kwashiorkor patients. Kwashiorkor is seen to affect glucose clearance in the blood causing a dysfunction in the beta-cells of the pancreas [3]. Pregnant mothers with PEM may affect inherent metabolic physiology of the fetus that my result to marasmus or Kwashiorkor when the baby is born [4].

1. Hyacinth HI, Adekeye OA, Yilgwan CS. Malnutrition in Sickle Cell Anemia: Implications for Infection, Growth, and Maturation. J Soc Behav Health Sci. Jan 2013; 1:7(1).
2. Bandsma RH, Spoelstra MN, Mari A, Mendel M, van Rheenen PF, Senga E, van Dijk T, Heikens GT. Impaired glucose absorption in children with severe malnutrition.J Pediatr. 2011; 158(2):282-7.e1 
3. Spoelstra MN, Mari A, Mendel M, et al. Kwashiorkor and marasmus are both associated with impaired glucose clearance related to pancreatic beta-cell dysfunction. Metabolism. Mar 2 2012;
4. Forrester TE, Badaloo AV, Boyne MS, Osmond C, Thompson D, Green C, et al. Prenatal factors contribute to the emergence of kwashiorkor or marasmus in severe undernutrition: evidence for the predictive adaptation model. PLoS One. 2012; 7(4):e35907.
5. Badaloo AV, Forrester T, Reid M, Jahoor F. Lipid kinetic differences between children with kwashiorkor and those with marasmus. Am J Clin Nutr. 2006; 83(6):1283-8 
6. Demling RH. The incidence and impact of pre-existing protein energy malnutrition on outcome in the elderly burn patient population. J Burn Care Rehabil. Jan-Feb 2005; 26(1):94-100.
7. Ahmad S, Ellis J, Nesbitt A, Molyneux E. Pericardial effusions in children with severe protein energy malnutrition resolve with therapeutic feeding: a prospective cohort study. Arch Dis Child. 2008; 93(12):1033-6 
8. Walmsley RS. Refeeding syndrome: screening, incidence, and treatment during parenteral nutrition. J Gastroenterol Hepatol. Dec 2013; 28 Suppl 4:113-7.
9. Oshikoya KA, Sammons HM, Choonara I. A systematic review of pharmacokinetics studies in children with protein-energy malnutrition. Eur J Clin Pharmacol. 2010; 66(10):1025-35 
10. Dorner TE, Lackinger C, Haider S, Luger E, Kapan A, Luger M, et al. Nutritional intervention and physical training in malnourished frail community-dwelling elderly persons carried out by trained lay "buddies": study protocol of a randomized controlled trial. BMC Public Health. Dec 2013; 13(1):1232.