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Marasmus


Presentation

The following system wise signs and symptoms are evident in cases of marasmus:

  • General appearance: Marasmic children may present with hypothermia due to an incompetent immune response or hyperthermia (fever) due to secondary bacterial infections. Patients may appear weak and thirsty due to dehydration of the body tissues. 
  • Integumentary system: Children with marasmus will present with pallor of skin and mucosae due to progressive anemia. Skin lesions like generalized and diffused purpura may herald an ongoing sepsis
  • Head and neck: Facial edema (myxedema) may ensue due to protein deficiency that causes osmotic gradient in the extracellular spaces. Eyeballs may appear sunken with thirst. Corneal lesions may surface due to vitamin A deficiency [6]. Otitis and rhinitis due to concurrent infections may also be seen in patients.
  • Chest and heart: These patient may appear with tachypnea due to complications of pneumonia and heart failure.
  • Abdomen: Marasmus will classically present with a distended abdomen due to ascites and hepatosplenomegaly. Bowel sounds will be slower due to electrolyte imbalance. Bleeding per anus may be evident with concomitant gastrointestinal bleeding.
  • Renal: Decreased urine output may be observable with complicated renal failure.
  • Extremities: Radial pulses may appear weak and extremities may be cold to feel due to shock
  • Neurologic: Patients may be brought in lethargy due to lack of energy and calories from starvation. Patients may appear confused due to the metabolic acidosis at play. 
Weight Loss
  • No impairment was found in 12 individuals with recent weight loss who remained at a weight greater than the 85% weight-height ratio.[ncbi.nlm.nih.gov]
  • ‘Patients with marasmus present with severe weight loss and wasting of both muscle and adipose tissue.’ Origin Mid 17th century: modern Latin, from Greek marasmos ‘withering’, from marainein ‘wither’. Pronunciation[en.oxforddictionaries.com]
  • In contrast, the importance of diarrhea in triggering malnutrition through anorexia and weight loss has been well established.[food4africa.org]
  • […] rates of metabolism. marasmus A state of severe malnutrition, due to ingestion of protein and calories, due to poor diet, feeding habits, parent-child relationship or metabolic defects Clinical FTT, weight loss, emaciation, skin turgor, skin and muscle[medical-dictionary.thefreedictionary.com]
Hyperthermia
  • The following system wise signs and symptoms are evident in cases of marasmus: General appearance: Marasmic children may present with hypothermia due to an incompetent immune response or hyperthermia (fever) due to secondary bacterial infections.[symptoma.com]
Myxedema
  • Head and neck: Facial edema (myxedema) may ensue due to protein deficiency that causes osmotic gradient in the extracellular spaces. Eyeballs may appear sunken with thirst. Corneal lesions may surface due to vitamin A deficiency.[symptoma.com]
Hepatosplenomegaly
  • Abdomen: Marasmus will classically present with a distended abdomen due to ascites and hepatosplenomegaly. Bowel sounds will be slower due to electrolyte imbalance. Bleeding per anus may be evident with concomitant gastrointestinal bleeding.[symptoma.com]
Psychomotor Retardation
  • The marasmic children exhibited growth retardation and muscle wastage but had normal serum protein values and absence of psychomotor retardation or oedema.[ncbi.nlm.nih.gov]

Workup

The diagnosis of marasmus as a malnutrition state will only require a comprehensive clinical evaluation of patients. The significant changes in the body composition during this protein energy malnutrition state can render laboratory tests to be unreliable at times. Laboratory test may be most useful in confirming clinical condition that may coexist with marasmus. The following laboratory tests are useful in the work of marasmus:

  • Blood glucose monitoring: This demonstrates hypoglycemic states in patients.
  • Peripheral blood smear (PBS): This could demonstrate parasites in the blood.
  • Hemoglobin test: Confirms the occurrence of severe anemia in marasmus.
  • Urinalysis and culture: Microscopy of urine will reveal many leukocytes with urinary infection and culture of urine may be done.
  • Stool examination: This could reveal intestinal parasites and blood in the feces.
  • Albumin tests: Albumin levels below 35 grams per liter suggests a severe impairment in protein production.
  • Electrolytes determination: Hyponatremia is usual finding in the late stages of marasmus.

Treatment

The medical care of marasmic cases is conveniently divided into the initial intensive phase, consolidation stage (rehabilitation), and preparing for outpatient follow-up management. The World Health Organization (WHO) recommends routine antibiotic coverage in all cases of marasmus as a preventive step [7]. This is further supported by cohort studies that suggests that antibiotic prophylaxis in uncomplicated malnutrition has been proven to hasten recovery and reduce mortality among Malawian children [8]. The WHO provides this guidelines in the treatment of marasmus in children:

  • Hypoglycemia monitoring and control
  • Treatment and prevention of progressive hypothermia
  • Prompt correction of dehydration
  • Early detection and correction of electrolyte imbalance
  • Active control of infections
  • Screening and stabilization of micronutrient deficiencies
  • Feeding for initial stabilization
  • Nutritional support to support normal growth
  • Psychological support, care and stimulation [9]
  • Careful follow-up of cases upon discharge [10]

Prognosis

The patient’s outlook is largely dependent on the cause of the malnutrition. Acute and less severe malnutrition is easily reversed in a hospital setting. However, malnutrition caused by an ongoing medical illness may need correction of the primary pathology before the malnutrition states are reversed. Concomitant illnesses like bacterial infection and renal failure may cause the patients to succumb rather than the malnutrition state per se.

Complications

The protein energy malnutrition in marasmus, if left untreated may complicate to either of these medical conditions:

Etiology

Marasmus is a serious form of malnutrition that affects more than 50 million children below 5 years of age worldwide. Children suffering from these form of malnutrition may have a very high mortality rate when afflicted by intercurrent illnesses [1].

Marasmus has a higher prevalence rate in low income and developing countries. Although studies have revealed that children in developed nations may have an occurrence of such protein energy malnutrition (PEM), it is also observed especially in hospitalized patients with malignancy, cystic fibrosis, neurologic diseases, genetic diseases and end stage renal diseases [2]. Marasmus directly affects mortality rate and morbidity rate in patients with prolonged disease [3]. It may also hamper linear growth and neurologic development.

Epidemiology

In the United States and in other developed countries, marasmus rarely occurs as a chronic malnutrition condition. However, acute protein energy malnutrition may still occur in hospitalized patients in lower incidence rates [4].

Internationally, 80% of these malnourished children reside in Asia, 15% in Africa and only 5% in Latin America [5]. An estimated 5 million patients each year die of malnutrition.

Sex distribution
Age distribution

Pathophysiology

The pathophysiology of marasmus is mainly weighted on the metabolic imbalance in the body system brought about by decreased energy intake, progressive loss of caloric intake, and increased expenditure of imbibed energy.

Chronic cases present with systemic adaptations like decrease in physical activity, decreases in basal energy metabolism, lethargy, growth stunting, and progressive weight loss. The long term effects of marasmus to the child’s body system is expressed physically in terms of change body composition, metabolic changes, and anatomical changes.

Prevention

All forms of malnutrition are prevented with proper eating and a balanced diet. Prophylactic antibiotics in early uncomplicated cases of marasmus lower mortality and increases recovery rates.

Summary

Marasmus is a clinical condition characterized by severe wasting of fats, muscles, and other tissues. Marasmus is a severe form of malnutrition where the body does not get enough protein and energy (calories) from food sources.

The spectrum of marasmus ranges from a singular vitamin deficiency to complete starvation. Marasmus is considered one of the most serious form of protein energy malnutrition in the world.

The World Health Organization (WHO) recognizes that 49% of all children death less than 5 years of age is due to protein energy malnutrition like marasmus.

Patient Information

Definition

Marasmus is a type of malnutrition clinically presenting as progressive wasting of muscles, fats and bodily tissues.

Cause

Protein energy malnutrition in starvation, long term hospitalization, malignancies and chronic diseases may lead to this condition.

Symptoms

Patients appear hypothermic, confused, lethargic, pale, dehydrated, and with a distended abdomen.

Diagnosis

Comprehensive history and clinical evaluation, and ancillary laboratory tests are done to diagnose marasmus.

Treatment and follow-up

Prompt nutritional support and correction of metabolic imbalances. Patients should be carefully followed up after they are discharged.

References

Article

  1. Pelletier DL, Frongillo EA Jr, Schroeder DG, Habicht JP. The effects of malnutrition on child mortality in developing countries. Bull World Health Org. 1995; 73 (4):443-8.
  2. Joosten KF, Hulst JM. Prevalence of malnutrition in pediatric hospital patients. Curr Opin Pediatr. Oct 2008; 20(5):590-6.
  3. Oztürk Y, Buyukgebiz B, Arslan N, Ellidokuz H. Effects of hospital stay on nutritional anthropometric data in Turkish children. J Trop Pediatr. Jun 2003; 49(3):189-90.
  4. Hendricks KM, Duggan C, Gallagher L, et al. Malnutrition in hospitalized pediatric patients. Current prevalence. Arch Pediatr Adolesc Med. Oct 1995; 149(10):1118-22.
  5. Fisberg M, Nobrega FJ. Disturbios da nutricao. Revinter. 1998; 140-4.
  6. Emery PW. Metabolic changes in malnutrition. Eye. October 2005; 19 (10):1029-32.
  7. Alcoba G, Kerac M, Breysse S, et al. Do children with uncomplicated severe acute malnutrition need antibiotics? A systematic review and meta-analysis. PLoS One. 2013; 8(1):e53184.
  8. Trehan I, Goldbach HS, LaGrone LN, et al. Antibiotics as part of the management of severe acute malnutrition. N Engl J Med. Jan 31 2013; 368(5):425-35.
  9. Waber DP, Bryce CP, Fitzmaurice GM, et al. Neuropsychological Outcomes at Midlife Following Moderate to Severe Malnutrition in Infancy. Neuropsychology. Mar 17 2014;
  10. World Health Organization. WHO Global Database on Child Growth and Malnutrition. Geneva: WHO. 1996.

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Last updated: 2017-08-09 18:12