Malnutrition in children in resource-limited countries

Malnutrition is a clinical state caused by an imbalance or deficiency of calories and/or micronutrients and macronutrients. The 2 main manifestations of acute severe malnutrition are marasmus (total caloric insufficiency) and kwashiorkor (protein malnutrition with characteristic edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema). Malnutrition is almost always associated with an underlying disease process, which can be classified into 4 categories: decreased nutrient intake, decreased absorption of micronutrients and macronutrients, increased nutrient loss, and increased energy expenditure. The clinical presentation of marasmus varies based on severity, duration of caloric restriction, and vitamin/mineral deficiencies. The clinical presentation of kwashiorkor includes peripheral pitting edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema, muscle atrophy, and abdominal distention. Anthropometry is essential in the diagnosis of malnutrition. The 3-step approach to treat malnutrition includes resuscitation, rehabilitation, and relapse prevention.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definition

Malnutrition is a clinical state with an imbalance, a deficiency, or an excess of a wide range of nutrients and energy.

  • Marasmus:
    • Inadequate caloric/nutrient intake 
    • Low weight-to-height ratio (< 3 standard deviations of the mean for age)
    • Muscle wasting and reduced adipose tissue Adipose tissue Adipose tissue is a specialized type of connective tissue that has both structural and highly complex metabolic functions, including energy storage, glucose homeostasis, and a multitude of endocrine capabilities. There are three types of adipose tissue, white adipose tissue, brown adipose tissue, and beige or "brite" adipose tissue, which is a transitional form. Adipose Tissue
  • Kwashiorkor:
    • Protein deficiency 
    • Usually sufficient calories (compensated diet)
    • Classic finding: edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema due to lack of intravascular colloid pressure
Malnutrition types

Two forms of severe acute malnutrition: edematous (kwashiorkor) and nonedematous (marasmus) malnutrition

Image: “Clinical picture” by Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark. License: CC BY 4.0

Epidemiology

  • Global prevalence for acute malnutrition: 
    • Moderate malnutrition: 32.7 million children
    • Severe wasting: 14.3 million children < 5 years of age
  • Primarily in resource-limited regions (e.g., South Asia and sub-Saharan Africa)

Etiology

Malnutrition is often associated with underlying disease and can be conceptually categorized into 4 broad etiological categories:

  • Decreased intake:
    • Lack of availability
    • Lack of access (e.g., difficulty physically reaching food and chewing food) 
  • Decreased absorption of micronutrients/macronutrients ( malabsorption Malabsorption Malabsorption involves many disorders in which there is an inability of the gut to absorb nutrients from dietary intake, potentially including water and/or electrolytes. A closely related term, maldigestion is the inability to break down large molecules of food into their smaller constituents. Malabsorption and maldigestion can affect macronutrients (fats, proteins, and carbohydrates), micronutrients (vitamins and minerals), or both. Malabsorption and Maldigestion):
    • Chronic diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
    • Lack of small bowel surface area
  • Increased loss and/or a change in energy requirements:
    • Pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care
    • Enterocutaneous fistula 
  • Increased energy expenditure:
    • Hypermetabolic states ( hyperthyroidism Hyperthyroidism Thyrotoxicosis refers to the classic physiologic manifestations of excess thyroid hormones and is not synonymous with hyperthyroidism, which is caused by sustained overproduction and release of T3 and/or T4. Graves' disease is the most common cause of primary hyperthyroidism, followed by toxic multinodular goiter and toxic adenoma. Thyrotoxicosis and Hyperthyroidism)
    • Specific pathological states (e.g., extensive burns Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns, cardiac dysfunction, and head injury)

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Clinical Presentation

Pathological changes caused by malnutrition

  • Basal metabolic rate ↓ by 30%
  • ↓ Protein synthesis  
  • Sodium-potassium pump dysfunction → increased intracellular sodium
  • Endocrine:
    • Insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin production
    • Insulin Insulin Insulin is a peptide hormone that is produced by the beta cells of the pancreas. Insulin plays a role in metabolic functions such as glucose uptake, glycolysis, glycogenesis, lipogenesis, and protein synthesis. Exogenous insulin may be needed for individuals with diabetes mellitus, in whom there is a deficiency in endogenous insulin or increased insulin resistance. Insulin-like growth factor (IGF) production
    • ↑ Cortisol production

Clinical presentation of marasmus

Clinical presentation varies based on severity, duration of caloric restriction, and presence of vitamin/mineral deficiencies.

Individuals present with:

  • Failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive:
    • Low weight for height
    • Decreased mid-upper arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm circumference (MUAC) 
  • Loss of adipose tissue Adipose tissue Adipose tissue is a specialized type of connective tissue that has both structural and highly complex metabolic functions, including energy storage, glucose homeostasis, and a multitude of endocrine capabilities. There are three types of adipose tissue, white adipose tissue, brown adipose tissue, and beige or "brite" adipose tissue, which is a transitional form. Adipose Tissue:
    • Begins in the groin or axilla Axilla The axilla is a pyramid-shaped space located between the upper thorax and the arm. The axilla has a base, an apex, and 4 walls (anterior, medial, lateral, posterior). The base of the pyramid is made up of the axillary skin. The apex is the axillary inlet, located between the 1st rib, superior border of the scapula, and clavicle. Axilla and Brachial Plexus → buttocks, face, and thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh
    • General appearance: shrunken and wasted
  • Signs unique to infants:
    • Sunken fontanelle (dehydration)
    • Irritability
    • Apathy/torpor 
  • Symptoms of marasmus associated with vitamin/mineral deficiencies: 
    • Vitamin A deficiency: dry eyes and Bitot spots
    • Iron deficiency and anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview: spoon nail (koilonychia)
    • Hypocalcemia Hypocalcemia Hypocalcemia, a serum calcium < 8.5 mg/dL, can result from various conditions. The causes may include hypoparathyroidism, drugs, disorders leading to vitamin D deficiency, and more. Calcium levels are regulated and affected by different elements such as dietary intake, parathyroid hormone (PTH), vitamin D, pH, and albumin. Presentation can range from an asymptomatic (mild deficiency) to a life-threatening condition (acute, significant deficiency). Hypocalcemia: hyperreflexia
      • Chvostek’s sign: twitching of the facial muscles in response to tapping over the area of the facial nerve.
      • Trousseau’s sign: carpopedal spasm caused by inflating the blood-pressure cuff to a level above systolic pressure for 3 minutes
  • Calcium and vitamin D deficiency: bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones deformities including rickets Rickets Rickets and osteomalacia are disorders of decreased bone mineralization. Rickets affects the cartilage of the epiphyseal growth plates in children. Although most cases of rickets are due to vitamin D deficiency, other genetic and nutritional disorders as well as medications can cause these disorders. Rickets commonly presents with skeletal deformities and growth abnormalities. Osteomalacia and Rickets and/or osteomalacia Osteomalacia Rickets and osteomalacia are disorders of decreased bone mineralization. Osteomalacia affects the sites of bone turnover in children and adults. Although most cases are due to vitamin D deficiency, other genetic and nutritional disorders as well as medications can cause these disorders. Osteomalacia can present with bone pain, difficulty with ambulation and pathologic fractures. Osteomalacia and Rickets
  • Long-standing marasmus:
    • Stunted growth 
    • Symptoms of anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview and rickets Rickets Rickets and osteomalacia are disorders of decreased bone mineralization. Rickets affects the cartilage of the epiphyseal growth plates in children. Although most cases of rickets are due to vitamin D deficiency, other genetic and nutritional disorders as well as medications can cause these disorders. Rickets commonly presents with skeletal deformities and growth abnormalities. Osteomalacia and Rickets
    • Impairment of cardiovascular function → hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension, hypothermia Hypothermia Hypothermia can be defined as a drop in the core body temperature below 35°C (95°F) and is classified into mild, moderate, severe, and profound forms based on the degree of temperature decrease. Hypothermia, and bradycardia
Bitot spots

Bitot spots resulting from vitamin A deficiency

Image: “Bitot spots” by Professor of Ophthalmology, College of Medicine, University of Ibadan, Nigeria. License: CC BY 2.0

Clinical presentation of kwashiorkor

Individuals present with:

  • Peripheral pitting edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema:  
    • Gravity-dependent edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema: begins in the lower extremities and moves cranially
    • Symmetrical
  • Significant muscle atrophy
  • Abdominal distention (with or without dilatation of the bowel loop and hepatomegaly)
  • Round face with prominent cheeks
  • Skin changes:
    • Dryness
    • Thinning 
    • Peels easily
    • Confluent areas of scaling and hyperpigmentation
    • Lesions and dermatitis in the perineum, groin, limbs, ears, and armpits
  • Hair changes:
    • Dryness
    • Hypopigmentation
    • Falls out/easily plucked
  • Growth retardation
  • Fat retention in the subcutaneous skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin is accompanied by loose skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin folds in the inner inguinal skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin.
Kwashiorkor presentation

A child with kwashiorkor: Ascites Ascites Ascites is the pathologic accumulation of fluid within the peritoneal cavity that occurs due to an osmotic and/or hydrostatic pressure imbalance secondary to portal hypertension (cirrhosis, heart failure) or non-portal hypertension (hypoalbuminemia, malignancy, infection). Ascites lead to protruding abdomen.

Image: “Kwashiorkor” by Av TKnoxB/Flickr. License: CC BY 2.0

Diagnosis

Malnutrition

Accurate anthropometry is essential in malnutrition diagnosis:

  • Vertical-length precision: 0.5 cm
  • Weight precision: 100 g
  • MUAC precision: 2 mm or less

Laboratory tests to consider:

  • Hemoglobin and CBC
  • Blood smear 
  • Blood glucose
  • Serum albumin
  • Stool microscopy and culture (ova and eggs included)
  • Urine microscopy and culture
  • HIV testing
  • Iron studies
  • Folic acid level
  • Vitamin B12 level

Marasmus

Diagnosis made if:

  • MUAC < 115 mm OR
  • Weight-for-height Z score > 3 standard deviations below the mean
  • Investigate pitting edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema to rule out kwashiorkor.

Kwashiorkor

  • Low MUAC
  • Symmetrical pitting edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
  • Other diagnostic criteria for kwashiorkor:
    • Hair hypopigmentation
    • Cheilosis
    • Dermatitis

Management

Stepwise approach

Divided into 3 main phases:

  1. Resuscitation and stabilization of the individual (approximately 1 week):
    • Goals:
      • Treatment and prevention of dehydration and correction of electrolyte imbalances:
        • The sodium in normal saline solution is too high and the potassium is too low.
        • ReSoMal (REhydration SOlution for MALnutrition) is a customized solution administered orally or through a nasogastric tube, which contains the exact amount of electrolytes Electrolytes Electrolytes are mineral salts that dissolve in water and dissociate into charged particles called ions, which can be either be positively (cations) or negatively (anions) charged. Electrolytes are distributed in the extracellular and intracellular compartments in different concentrations. Electrolytes are essential for various basic life-sustaining functions. Electrolytes, minerals, water, and sugar needed.
      • Treatment and prevention of infection:
        • Individuals may not present with an overt response to sepsis Sepsis Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock.
        • Give antibiotics to individuals with suspected infection.
      • Treatment and prevention of hypothermia Hypothermia Hypothermia can be defined as a drop in the core body temperature below 35°C (95°F) and is classified into mild, moderate, severe, and profound forms based on the degree of temperature decrease. Hypothermia
    • Prevention of refeeding syndrome:
      • Nutrition should be delivered at a slow rate with a caloric intake between 60% and 80% of age-specific needs. 
      • Hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia is a risk of refeeding syndrome: Recommend continuous nasogastric feeds or small meals at night to avoid hypoglycemia.
      • Administer thiamine and oral phosphate to prevent hypophosphatemia.
  2. Nutritional rehabilitation (2–6 weeks):
    • Caloric intake can be increased to 120%–140% of age-specific requirements.
    • Administer needed vaccinations.
    • Encourage increased motor activity.
    • Mother/child bonding is beneficial to reverse developmental delay and provide sensory stimulation and emotional support.
  3. Follow-up and prevention of recurrence:
    • Educate the caregiver (especially for breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding considerations and supplemental feeding).
    • Infectious disease control and a continuous supply of adequate nutrition and clean drinking water are crucial.

Key considerations:

  • Fluid imbalance is a significant issue in kwashiorkor:
    • Rehydrate vigilantly.
    • Aggressive rehydration may cause acute heart failure and severe hypovolemia, resulting in shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock and death.
  • If an infant is < 6 months of age, a MUAC < 110 mm is highly associated with mortality.

Complications

Refeeding syndrome

  • Intracellular/extracellular electrolytes Electrolytes Electrolytes are mineral salts that dissolve in water and dissociate into charged particles called ions, which can be either be positively (cations) or negatively (anions) charged. Electrolytes are distributed in the extracellular and intracellular compartments in different concentrations. Electrolytes are essential for various basic life-sustaining functions. Electrolytes and fluid levels are abnormal in malnourished individuals.
  • Feeding and hydration performed too rapidly cause unexpected shifts in fluids and electrolytes Electrolytes Electrolytes are mineral salts that dissolve in water and dissociate into charged particles called ions, which can be either be positively (cations) or negatively (anions) charged. Electrolytes are distributed in the extracellular and intracellular compartments in different concentrations. Electrolytes are essential for various basic life-sustaining functions. Electrolytes.
  • Hallmarks of refeeding syndrome:
    • Edema
    • Seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures
    • Rhabdomyolysis Rhabdomyolysis Rhabdomyolysis is characterized by muscle necrosis and the release of toxic intracellular contents, especially myoglobin, into the circulation. Rhabdomyolysis 
    • Hypophosphatemia
    • Hypokalemia Hypokalemia Hypokalemia is defined as plasma potassium (K+) concentration < 3.5 mEq/L. Homeostatic mechanisms maintain plasma concentration between 3.5-5.2 mEq/L despite marked variation in dietary intake. Hypokalemia can be due to renal losses, GI losses, transcellular shifts, or poor dietary intake. Hypokalemia

Cardiac and pulmonary implications

  • Cardiac muscle mass reduction → cardiac output decreases → decrease in renal perfusion and glomerular filtration Glomerular filtration The kidneys are primarily in charge of the maintenance of water and solute homeostasis through the processes of filtration, reabsorption, secretion, and excretion. Glomerular filtration is the process of converting the systemic blood supply into a filtrate, which will ultimately become the urine. Glomerular Filtration rate
  • Weakened diaphragmatic and respiratory muscle function → reduction in cough pressure and decreased secretion expectoration → delayed respiratory tract infection recovery

Gastrointestinal consequences

  • Pancreatic insufficiency
  • Altered intestinal permeability, villous architecture, and intestinal blood flow:
    • Ion and fluid secretions occur in the small and large bowel.
    • The colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix loses the ability to reabsorb water and electrolytes Electrolytes Electrolytes are mineral salts that dissolve in water and dissociate into charged particles called ions, which can be either be positively (cations) or negatively (anions) charged. Electrolytes are distributed in the extracellular and intracellular compartments in different concentrations. Electrolytes are essential for various basic life-sustaining functions. Electrolytes.
  • Leads to diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea → high mortality rate in severely malnourished
  • Individuals may develop ileus, lactase deficiency, or bacterial overgrowth, which may progress to septicemia and death.

Immunity and wound healing Wound healing Wound healing is a physiological process involving tissue repair in response to injury. It involves a complex interaction of various cell types, cytokines, and inflammatory mediators. Wound healing stages include hemostasis, inflammation, granulation, and remodeling. Wound Healing

  • Impaired cell-mediated immunity and altered cytokine, complement, and phagocyte function → increased risk of infection
  • Delayed wound healing Wound healing Wound healing is a physiological process involving tissue repair in response to injury. It involves a complex interaction of various cell types, cytokines, and inflammatory mediators. Wound healing stages include hemostasis, inflammation, granulation, and remodeling. Wound Healing is observed in malnourished surgical individuals.

Psychosocial impact

  • Apathy
  • Depression
  • Neglect of self
  • Anxiety

Differential Diagnosis

  • Human immunodeficiency virus Virus Viruses are infectious, obligate intracellular parasites composed of a nucleic acid core surrounded by a protein capsid. Viruses can be either naked (non-enveloped) or enveloped. The classification of viruses is complex and based on many factors, including type and structure of the nucleoid and capsid, the presence of an envelope, the replication cycle, and the host range. Virology: Overview (HIV): a single-stranded RNA RNA Ribonucleic acid (RNA), like deoxyribonucleic acid (DNA), is a polymer of nucleotides that is essential to cellular protein synthesis. Unlike DNA, RNA is a single-stranded structure containing the sugar moiety ribose (instead of deoxyribose) and the base uracil (instead of thymine). RNA generally carries out the instructions encoded in the DNA but also executes diverse non-coding functions. RNA Types and Structure virus Virus Viruses are infectious, obligate intracellular parasites composed of a nucleic acid core surrounded by a protein capsid. Viruses can be either naked (non-enveloped) or enveloped. The classification of viruses is complex and based on many factors, including type and structure of the nucleoid and capsid, the presence of an envelope, the replication cycle, and the host range. Virology: Overview transmitted sexually or through blood-to-blood contact. The virus Virus Viruses are infectious, obligate intracellular parasites composed of a nucleic acid core surrounded by a protein capsid. Viruses can be either naked (non-enveloped) or enveloped. The classification of viruses is complex and based on many factors, including type and structure of the nucleoid and capsid, the presence of an envelope, the replication cycle, and the host range. Virology: Overview attacks CD4 T lymphocyte cells, macrophages, and dendritic cells leading to immunodeficiency. The presentation is marked by constitutional symptoms, such as lymphadenopathy Lymphadenopathy Lymphadenopathy is lymph node enlargement (> 1 cm) and is benign and self-limited in most patients. Etiologies include malignancy, infection, and autoimmune disorders, as well as iatrogenic causes such as the use of certain medications. Generalized lymphadenopathy often indicates underlying systemic disease. Lymphadenopathy and fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever. Immediate treatment with combination antiretroviral therapy Antiretroviral therapy Antiretroviral therapy (ART) targets the replication cycle of the human immunodeficiency virus (HIV) and is classified based on the viral enzyme or mechanism that is inhibited. The goal of therapy is to suppress viral replication to reach the outcome of undetected viral load. Anti-HIV Drugs is recommended.
  • Inflammatory bowel disease: a chronic pathological condition of the bowels divided into Crohn’s disease and ulcerative colitis Ulcerative colitis Ulcerative colitis (UC) is an idiopathic inflammatory condition that involves the mucosal surface of the colon. It is a type of inflammatory bowel disease (IBD), along with Crohn's disease (CD). The rectum is always involved, and inflammation may extend proximally through the colon. Ulcerative Colitis. Crohn’s disease (CD) is a chronic, recurrent condition causing patchy, transmural inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation involving any part of the GI tract. Ulcerative colitis ( UC UC Ulcerative colitis (UC) is an idiopathic inflammatory condition that involves the mucosal surface of the colon. It is a type of inflammatory bowel disease (IBD), along with Crohn's disease (CD). The rectum is always involved, and inflammation may extend proximally through the colon. Ulcerative Colitis) is an idiopathic inflammatory condition involving the mucosal surface of the colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix. Extraintestinal manifestations of CD include calcium oxalate renal stones, gallstones, erythema nodosum Erythema nodosum Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum, and arthritis. Extraintestinal manifestations of UC UC Ulcerative colitis (UC) is an idiopathic inflammatory condition that involves the mucosal surface of the colon. It is a type of inflammatory bowel disease (IBD), along with Crohn's disease (CD). The rectum is always involved, and inflammation may extend proximally through the colon. Ulcerative Colitis include primary sclerosing cholangitis Primary Sclerosing Cholangitis Primary sclerosing cholangitis (PSC) is an inflammatory disease that causes fibrosis and strictures of the bile ducts. The exact etiology is unknown, but there is a strong association with IBD. Patients typically present with an insidious onset of fatigue, pruritus, and jaundice, which can progress to cirrhosis and complications related to biliary obstruction. Primary Sclerosing Cholangitis, eye inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation, oral ulcerations, and erythema nodosum Erythema nodosum Erythema nodosum is an immune-mediated panniculitis (inflammation of the subcutaneous fat) caused by a type IV (delayed-type) hypersensitivity reaction. It commonly manifests in young women as tender, erythematous nodules on the shins. Erythema Nodosum.
  • Nephrotic syndrome Nephrotic syndrome Nephrotic syndrome is characterized by severe proteinuria, hypoalbuminemia, and peripheral edema. In contrast, the nephritic syndromes present with hematuria, variable loss of renal function, and hypertension, although there is sometimes overlap of > 1 glomerular disease in the same individual. Nephrotic Syndrome: a broad category of glomerular diseases characterized by severe proteinuria, hypoalbuminemia, edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema, and hyperlipidemia. The clinical presentation of nephrotic syndrome includes edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema (peripheral and periorbital), frothy urine (lipiduria from hyperlipidemia), hypoalbuminemia, and variable Variable Variables represent information about something that can change. The design of the measurement scales, or of the methods for obtaining information, will determine the data gathered and the characteristics of that data. As a result, a variable can be qualitative or quantitative, and may be further classified into subgroups. Types of Variables degrees of renal dysfunction. Management varies with etiology and usually involves glucocorticoids Glucocorticoids Glucocorticoids are a class within the corticosteroid family. Glucocorticoids are chemically and functionally similar to endogenous cortisol. There are a wide array of indications, which primarily benefit from the antiinflammatory and immunosuppressive effects of this class of drugs. Glucocorticoids.
  • Pancreatitis: persistent inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation, fibrosis, and irreversible cell damage to the pancreas Pancreas The pancreas lies mostly posterior to the stomach and extends across the posterior abdominal wall from the duodenum on the right to the spleen on the left. This organ has both exocrine and endocrine tissue. Pancreas secondary to multiple etiologies (e.g., neoplasm, infection, and alcoholism), resulting in a loss of endocrine and exocrine gland function. Individuals often present with recurrent epigastric abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, nausea, and features of malabsorption Malabsorption Malabsorption involves many disorders in which there is an inability of the gut to absorb nutrients from dietary intake, potentially including water and/or electrolytes. A closely related term, maldigestion is the inability to break down large molecules of food into their smaller constituents. Malabsorption and maldigestion can affect macronutrients (fats, proteins, and carbohydrates), micronutrients (vitamins and minerals), or both. Malabsorption and Maldigestion syndrome (e.g., diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea, steatorrhea, and weight loss). Therapy focuses on alcohol cessation, diet changes, pain management Pain Management Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Pain is a subjective experience. Acute pain lasts < 3 months and typically has a specific, identifiable cause. Pain Management, and treatment of pancreatic insufficiency.

References

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  2. de Waal A., Whiteside A. (2003). New variant famine: AIDS and food crisis in southern Africa. Lancet. https://www.ncbi.nlm.nih.gov/pubmed/14568749
  3. Elia M., editor. Guidelines for detection and management of malnutrition. Malnutrition Advisory Group, Standing Committee of BAPEN. Maidenhead: BAPEN, 2000. 
  4. Grellety E., Golden M.H. Severely malnourished children with a low weight-for-height have a higher mortality than those with a low mid-upper-arm-circumference: I. Empirical data demonstrates Simpson’s paradox. Nutr J. 2018 Sep 15;17(1):79.
  5. Grellety E., Golden M.H. Severely malnourished children with a low weight-for-height have similar mortality to those with a low mid-upper-arm-circumference: II. Systematic literature review and meta-analysis. Nutr J. 2018 Sep 15;17(1):80. 
  6. Grover Z., Ee L.C. Protein energy malnutrition. Pediatr Clin North Am. 2009 Oct;56(5):1055–68.
  7. Ibrahim M.K., Zambruni M., Melby C.L., Melby P.C. Impact of Childhood Malnutrition on Host Defense and Infection. Clin Microbiol Rev. 2017 Oct;30(4):919–971.
  8. Müller O., Krawinkel M. (2005). Malnutrition and health in developing countries. CMAJ. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1180662/
  9. Sachs J.D., McArthur J.W. (2005). The Millennium Project: a plan for meeting the Millennium Development Goals. Lancet. 347–53. https://pubmed.ncbi.nlm.nih.gov/15664232/
  10. Stratton R., Green C.J., Elia M. (2003). Disease-related malnutrition: an evidence-based approach to treatment. Oxon: Cabi Publishing.
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