Case Report:

Kwashiorkor
BY:
JAYA DEV (110100465)
SUPERVISOR:
DR. HJ. TIANGSA SEMBIRING, M.KED (PED), SP.A(K)

50% of the
10 million
deaths in
each year
children
<5years

Suspectible
to infection

Protein
Energy
Malnutrition

3 forms:
Marasmus
Kwashiorkor
Marasmickwashiorkor

Riskesdas
2013, 17.9%
anak gizi
kurang 5,7%
gizi buruk

TYPES OF PEM

Kwashiorkor:

- Insufficient protein
consumption

Marasmus
Energy deficiency
Marasmic-Kwashiorkor

- Deficiency of both calories

and protein

KWASHIORKOR

Weight loss:

- arms and legs

- decrease of muscle mass

Swollen abdomen

- ascites: increase of capillary

permeability
- enlarged liver: fatty liver

Peripheral oedema: decrease of

oncotic pressure

Anemia: lethargy

Hair and skin changes

Treatment of PEM

Stabilization Phase
Transitional Phase
Rehabilitation Phase
Follow-up Phase

Types of condition in PEM

Objective
To report the case of boy DT, 2 months 2 days
.
kwashiorkor.

diagnosed with

Case
DT, 2 months 2 days old boy was admitted on December, 14th 2015 at
time 09:00 pm with complaint of swelling of his whole body. It has been
occured since 3 days ago. Swelling started from his scrotum and spread
to his both lower extremities and then throughout his whole body. History
of inadequate breastfeeding (+) and was given formula milk instead of
breastmilk. An ulcer is found at the parietal part of his skull .Started with
swelling and later on with the presence of pus (+) Blueness of his skin
was not found. Shortness of breath and Coughing was not found. Nausea
and Vomitting (-), anoreksia (+). Fever (+) since 5 days before
admission, the temperature was not too high and was decreased by antipyretic drug. History of spasm and convulsions(-). Urinating system was
normal, with yellow clear in the color with a lesser amount of urine,
defecation was normal with a normal stool consistensy During the
admission the fever was still occured.

History of previous illness:

He had ever been hospitalized in RS Royal Prima at the early of

December of 2015 for High fever and was given paracetamol and
rehydration solution. After being discharged, he never got to control and
never frequently took the medication given by the doctor for his illness.

History of birth : born caesarean section, immediately crying upon

birth,with no no blueness found. with the birth weight of 3200gr PBL=50cm

History of nutrition : formula milk (+), and additional food was also
given

History of obstetric : the mother was 39 years old when she was having
him, no history of consuming drugs and herbs, no history of having DM and
hypertension during pregnancy

History of immunization: : not clear

Physical Examination
General status

Body weight

4,4 kg

Body length

54 cm

Head circumference

37cm

Mid-upper arm circumference

12cm

Weight-for-age

-2<z-scores<0

Length-for-age

-2<z-scores<0

Weight-for-length

1<z-scores<0

normal

Presence status

Consciousness

: alert

Blood Pressure

: 90/40 mmHg

Heart Rate

: 128 x/i

Respiratory Rate : 48 x/i

Body Temperature

Anemic (+) Icteric (-) Cyanosis (-) Edema (-) Dyspnea (-)

: 37,8 oC

Local Status

Head
swelling of the head, wound (+) side part of the head
isochoric pupil, pale inferior palpebra conjunctiva, light
reflex on both eyes. Ears/ nose/ mouth: within normal limit

Neck
No lymph node enlargement

Thorax

Symmetrical fusiformis, intercostal space clearly visible,

protruding spine. HR: 128x/i, regular, murmur (-). RR:
39x/i, regular, ronchi (-), breath sound: vesicular,
additional sound (-)

Abdomen
Swelling (+) symmetrical , normal peristaltic, liver and
spleen unpalpable, skin pinch returns quickly

Extremities
Hypothrophy muscle (-). Pulse 128x/i, regular, adequate
pressure and volume, warm, CRT < 3, pitting edema (+)

Differential Diagnosis:
Kwashiorkor dd 1) nephrotic syndrome,+ Suspect Sepsis +
Abcess o/t (L) Parietalis

Working Diagnosis:
Kwashiorkor +Suspect Sepsis + Abcess o/t (L) Parietalis

Management:

O2 -1 L/mnt

Gentamycin ointment 2x1 applyc

Diagnostic Planning:

Complete Blood Test

Albumin

Blood Glucose

Urin Analysis

Septic work up

Electrolytes

Laboratory Finding: October 15th , 2015

Haematology

Result

Normal

7.40

11.1 14.4

Eritrocyte

2.26

3.71 - 4.25

Leucocyte

12.68

6.0 - 17.5

22.0

35 41

49

217 497

Haemoglobin

Haematocrite

g/dL

Thrombocyte
MCV

fL

92.90

82 100

MCH

pg

32.80

24 - 30

MCHC

g%

35.20

28 - 32

RDW

15.90

14.9 - 18.7

Neutrofil

46.30

37 80

Limphocyte

28.00

20 40

Monocyte

22.00

28

Eosinofil

3.30

16

Basofil

0.400

01

From the table above, we found anemia and

thrombocytopenia.

Haemostasis
Prothrombin Time
Patient

Control

Result
seconds
seconds

INR
APTT
Patient

Control

Thrombin Time
Patient

Control

Normal

17.2
13.8
1,26

seconds
seconds

28.2
32.0

seconds
seconds

15.6
17.5

Clinical Chemistry

Result

Normal

Random Blood Glucose

g/dL

44.90

40-60

Ureum

mg/dL

37.30

<50

Creatinine

mg/dL

0.39

0.17-0.42

albumin

2.0

3,8 5,4

Natrium (Na)

mEq/L

130

135-155

Kalium (K)

mEq/L

3.6

3.6 5.5

Chloride (Cl)

mEq/L

101

96-106

Urinalysis Complete Urine

Color
Glucose
Bilirubin
Keton
Spesific gravity
pH
Protein
Urobilinogen
Nitrit
Leucocyte
Blood
Urine Sediment
Erytrocyte
LPB
Leucocyte
LPB
Epitel
LPB
Casts
LPB
Cristal
LPB

Result
Yellow clear
Negative
Negative
Negative
1.000
7.0
Negative
Negative
Negative
Negative
Negative

Normal
Yellow
Negative
Negative
Negative
1.005 1.030
5-8
Negative

0-1
0-1
0-1
Negative
Negative

<3
<6

Negative
Negative

Negative

ELECTROLYTE

NORMAL

Calcium

Mg/dl

8,2

Sodium
Potassium
Chloride

MEq/l
MEq/l
Meq/l

137 (135-155)
4,7 (3,6-5,5)
106 (96-106)

(8,4-10,8)

Follow Up 14/12/2015
S

weakness, pale (+) swelling in his whole body (+)

Sens : Alert, T : 36,8 C, BW : 4,4kg, BH : 54cm

Head: swelling (+) and wound (+) side part of head, pus (+) eye reflect +/
+, isocor, pale conj. palpebra inferior+/+,
Ear/Nose/Mouth: normal
Neck: JVP R+2 cm H2O
Thorax : Symmetrical fusiform, retraction (-), HR : 130x/I, reguler,
murmur (-) RR : 44x/i, reguler, ronchi -/Abdomen : swelling (+) symmetrical, normal peristaltic, Hepar: not
palpeble Lien: not palpeble
Extremities : pulse 130 bpm reguler, adequate pressure and volume, warm,
CRT <3, pretibial edema (+)
Anogenital: scrotum swelling (+)

Kwashiorkor + suspect sepsis + abcess o/t(L) parietalis

O2 -1 L/minute
gentamycin ointment 2x1 apply c
R/ Scheduled for albumin correction, albumin = 2,0g/dl
Albumin 20% 9,4ml
Albumin 25% 7,52 ml

Consult nutrition and metabolic disease division

Consult infection and trophic disease division

Follow Up 15/12/2015 16/12/2015

S

pale, swelling in his whole body (+), weakness (+), fever (-)

Sens : Alert, T : 37,5 C, BW : 4,4kg, BH : 54cm

Head: swelling (+) ,wound (+) side part of head , pus (+) eye reflect +/+,
isocor, pale conj. Palpebra inferior +/+, Ear/Nose/Mouth: normal
Neck: JVP R+2 cm H2O
Thorax : Symmetrical fusiform, retraction (-), HR : 130x/I, reguler, murmur (-)
RR : 34x/i, reguler, ronchi -/Abdomen : swelling (+) symmetrical, normal peristaltic, Hepar: not palpeble
Lien: not palpeble
Extremities : pulse 130x/i, reguler, adequate pressure and volume, warm, CRT
<3, pretibial edema (+)
Anogenital : scrotum swelling (+)
Result from infection and trophic division : R/ clandamisin syrp 30mg/6hrs

Kwashiorkor + suspect sepsis + abcess o/t (L) parietalis

O2 -1 L/minute
gentamycin ointment 2x1 apply c

Scheduled pus culture at the back of his head

Full blood check up,Blood Glucose,Albumin,procalcitonin,CRP
kuanititative
Blood culture , iron profile, reticulocyte coombs test

Follow Up 17/12/2015-20/12/2015
S

pale, weakness (+), fever (-), swelling in whole body (+)

Sens : Alert, T : 37,5 C, BW : 4,4kg, BH : 54cm

Head: swelling (+) , wound (+) side part of head ,pus (+) eye reflect +/+, isocor, pale conj. Palpebra
inferior+/+, Ear/Nose/Mouth: normal
Neck: JVP R+2 cm H2O
Thorax : Symmetris fusiformis, retraction (-), HR : 118x/I, reguler, murmur (-) RR : 34x/i, reguler, ronchi
-/Abdomen : swelling (+), normal peristaltic, Hepar: not palpeble Lien: not palpable
Extremities : pulse 118x/i, reguler, adequate pressure and volume, warm, CRT <3 , pretibial edema (+)
Anogenital: scrotum swelling (+)
Laboratorium result 17/12/2016:
Hb/ht/leu/thrombosit/=7,7/21,9/19.400/90.000
Blood glucose=86mg/dl
pH = 7,4
Albumin: 2,2g/dl
Crp quantitative: 2,8 mg/dl
Procalcitonin:o,61
Ferritin 446.00mg/dl
Fe/iron 30mg/dl
TIBC 159ug/dl
Reticulocyte 1,39
Coombs test negative

Kwashiorkor + suspect sepsis + abcess o/t (L) parietalis

IVFD D5% NaCl 0,225% 20gtt/I (micro)

Inj. Ampicillin 250mg/6hrs
Inj gentamycin 25mg/12hrs/iv
Diet milk 55ml/3hours
R/transfusion PRC 50ml(kebutuhan 150ml)
Scheduled for albumin correction, Albumin 20% 5,65ml,
Albumin 25% 4,52ml

Scheduled for feses rutin blood culture pus culture, consult to nutrition
and metabolic disease division

Follow Up 21/12/2015-23/12/2015
S

Pale (+) weakness (+), swelling in his whole body(+)

Sens : Alert, T : 37,2 C, BW : 4,4kg, BH : 54cm

Head: swelling (+) wound (+) side part of head , pus (+) eye reflect +/+, isocor, pale conj. Palpebra inferior
+/+, Ear/Nose/Mouth: normal
Neck: JVP R+2 cm H2O
Thorax : Symmetrical fusiform, retraction (-), HR : 104x/I, reguler, murmur (-) RR : 26x/i, reguler, ronchi
-/Abdomen : swelling (+) symmetrical, normal peristaltic, Hepar: not palpeble Lien: not palpable
Extremities : pulse 104x/i, reguler, adequate pressure and volume, warm, CRT <3 , pretibial edema (+)
Anogenital : scrotum swelling (+)
Nutrition and metabolic division result :
Diet f-75 pregestimil 45gr milk+9gr sugar+8gr oil into 8x given
5ml/3hours/oral
Lab result 21/12/2015:
Hb/leuko/eritro/thrombo
15,5/5,17/9,79/45.50/179
Albumin
3,1g/dl
Results of urine culture: klebsiella pneumonia
Results of blood culture : Staphylococcus epidermidis.
Pus culture : normal
Feces culture: Parasite (-), leucocyte (-) blood(-).

Results of urine culture: klebsiella pneumonia

Results of blood culture : Staphylococcus epidermidis.
Pus culture : normal
Feces culture: Parasite (-), leucocyte (-) blood(-)

A
P

Kwashiorkor + cellulitis o/t region occipital + UTI ec klebsiella

pneumonia + sepsis ec staphylococcus epidermidis
IVFD D5% NaCl 0,225% 20gtt/I (micro)
Inj. Ampicillin 250mg/6hrs
Inj gentamycin 25mg/12hrs/iv
Diet f-75 pregestimil 45gr milk+9gr sugar+8gr oil into 8x given
5ml/3hours
R/transfusion PRC 50ml (kebutuhan 150ml)
Nystatin drop 4x1cc

Follow Up 24/12/2015- 30/12/2015

S

Weakness (+)pale (-)

Sens : Alert
T : 37,1 C
BW : 4,4kg
BH : 54cm
Head:wound(+) side part of his head, covered(+) eye reflect +/+, isocor, pale conj. Palpebra inferior -/-,
Ear/Nose/Mouth: normal
Neck: JVP R+2 cm H2O
Thorax : Symmetris fusiformis, retraction (+), HR : 120x/I, reguler, murmur (-) RR : 28x/i, reguler, ronchi -/Abdomen : soepel, normal peristaltic, Hepar: nonpalpeble
Lien: Not palpable
Extremities : pulse 120x/i, reguler, adequate pressure and volume, warm, CRT <3, pretibial edema (-)
Anogenital: scrotum swelling(-)
Resuts from nutrition division:
Diet f100 modifikasi pregestinal 62,8gr +24 gr sugar+4gr oil
5ml/3 hours/oral mixed with 70ml liquid

Kwashiorkor + cellulitis o/t region occipital + UTI ec klebsiella pneumonia + sepsis ec staphylococcus epidermidis

IVFD D5% NaCl 0,225% 20gtt/I (micro)

Inj.vancomycin 100mg/8hours/iv in nacl 0,9% 100ml
(finish in 2 hours)
Paracetamol 50mg(k/p)
Nystatin drop 4x1cc gentamycin
Dietf100 modification pregestinal 62,8gr +24 gr
sugar+4gr oil
5ml/3 hours/oral mixed with 70ml liquid water

Follow Up 30/12/2015- 4/01/2016

S

Pale (-) weakness (-)

O : Sens : Alert
T : 37,1 C
BW : 4,4kg
BH : 54cm
Head: swelling (-) wound (+) side of his head , covered(+) eye reflect
+/+, isocor, pale conj. Palpebra inferior -/-, Ear/Nose/Mouth: normal
Neck: JVP R+2 cm H2O
Thorax : Symmetris fusiformis, retraction (+), HR : 120x/I, reguler,
murmur (-) RR : 28x/i, reguler, ronchi -/Abdomen : soepel, normal peristaltic, Hepar: non palpeble Lien: Not
palpable
Extremities : pulse 120x/i, reguler, adequate pressure and volume,
warm, CRT <3, pretibial edema (-)
Anogenital: scrotum swelling(-)
PBJ
A :Kwashiorkor + cellulitis o/t region occipital + UTI ec klebsiella
pneumonia + sepsis ec staphylococcus epidermidis

P
IVFD D5% NaCl 0,225% 20gtt/I (micro)
Inj.vancomycin 100mg/8hours/iv in nacl 0,9% 100ml (finish in
2 hours)
Paracetamol 50mg(k/p)
Nystatin drop 4x1cc gentamycin
Dietf100 modification pregestinal 84,85gr +26,3 gr sugar+65ml
mixed with water
80ml/3jam(HS) with 1,6ml mineral mix

Discussion
Epidemiology
Kwashiorkor is most seen in developing countries
and widespread in Africa, South East Asia and
Central America.
The typical age presentation is below age 1-3 years
old and kwashiorkor affects boys and girls equally

In this case a patient, boy age 2 months 2 days

comes with the complain of swelling in his whole
body

 Etiology
1. inadequate protein diet intake which is mainly
acquired from breastfeeding of babies from age 0-6
months
2.Social-Economy status
Poor family statuses and low salary income causes
inbalance in nutrition intake
3.Infection
Infection worsens the nutritional state

In this case there is inadequate breastfeeding found

and the family comes from a poor background

 Clinical

Presentation of Kwashiorkor

Failure to grow
Loss of muscle mass
General oedema ( face , legs and abdomen )
Changes in hair and skin
Diarrhea
Enlarged Liver/ fatty liver
Anemic
Changes in mental status such as lethargia and irritability

According to the case:

Swelling found in scrotum then spread to his

extremities and abdomen and face.
Pasien found anemic.

Diagnosis of Kwashiorkor
1. History taking
swelling , Loss of growth , low body weight , diarrhea
Anoreksia weakness, pale and previous history of sickness
2. Physical examination
Changes in mental status
Oedema ( face ,upper and lower extremities and abdomen)
Muscle atrophy
Changes in hair and skin
Anemic
Palpable liver ( liver enlargement)
3. Laboratorium test

Changes in blood test

Changes in protein serum (eg Albumin)

Changes in electrolyte analysis

According to case report:

Pasien complains swelling in whole body , anoreksia , pale and
weakness.
On the physical examination oedema was found ( head , both
upper and lower extremities abdomen and scrotum)
Laboratorium test: hb level was found low followed by
thrombocyte level and low albumin level

 Terapy/Treatment

based on theory

Given based on type of condition I,II,III,IV,V

Consist of four stage
-Stabilization phase ( day 1-2)
-Transition phase (day 3-7)
-Rehabilitasion phase ( week 2-6)
-Follow up phase ( week 7-26)

Based on the theory is given based on condition V

50ml glucose and the first 2 hrs is given F75 every 30 mins
according to the BW.
10 hrs later continue with f 75 every 2 hrs and if the patient
finishes most of f75 proceed to every 3 hrs
If patient finishes complete the f 75 and also breastmilk ,
treatment is given every 4 hrs
Monitoring is done
At the end of stabilization phase f 75 replaced with f 100 and
is given every 4 hrs according to BW

 Antibiotics

( if malnutrition with infection)

Gentamycin iv or im (7,5 mg/kgBW) every day for 7 days

or
Ampicillin iv or im (50mg/kgBW) every 6 hrs for two days
Followed by amoksisillin (15mg/kgBW) every 8 hrs for 5 days

Case:
(the stabilization and transition phase )
Diet milk 55ml/3 hours and F-75 pregestimil every 3 hours
ampicillin and gentamycin antibiotics
(start rehabilitation phase)
catch-up feeding F-100 modification 80cc every 3 hours and
1,6cc mineral mix
vancomycin

Prognosis
Usually good but if treated only at ( late stages) can be fatal

Summary

DT, boy, age 2months and 2days comes on 14 th December 2015 with swelling
throughout his whole body(+) which starts from scrotum and then spreads to
his lower extremities and whole body and was diagnosed with Kwashiorkor +
cellulitis o/t occipitalis + UTI ec klebsiella pneumonia + sepsis ec
staphylococcus epidermidis and currently undergoing treatment such as:

IVFD D5% and NaCl 0,225% 10gtt/I micro

Vancomycin inj 100mg in 100ml Nacl 0,9% complete in 1 hour

Paracetamol 500mg (k/p)

Gentamycin zalf

Nystatin drop 4x1cc

Diet F100 modification pregestimil (84,85 gr milk , 26,3 gr sugar diluted in 65

ml and consume with 80ml/3 hours with 1,6 ml mineral mix)

Thank You