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Scaly Dermatitis and Edema in an Irritable Child

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 19-month-old boy presented for evaluation of widespread edema and acute dermatitis. Following an upper respiratory tract infection 1 month prior, he developed disseminated red, scaly patches and a progressive eruption of hyperpigmented and hypopigmented patches of skin. He had occasional nonbloody loose stools but no fevers or vomiting. Although he was otherwise well, his growth had fallen from the 75th to the 25th percentile for height and weight over the preceding 9 months, and he could speak only 2 words. His medical history was notable for atopic dermatitis and diarrhea in infancy that prompted allergy testing at age 6 months; he was subsequently diagnosed with milk, egg, and peanut allergies. His parents avoided feeding him these foods, providing him only soy-based milk and formula, with improvement of dermatitis, until age 1 year. Since then his diet had consisted of multiple rice milk feeds daily, supplemented only with pureed fruits and vegetables, pasta, snack puffs, and sunflower butter. The patient had no history of meconium ileus or family history of cystic fibrosis. There was no recent travel and no changes to the home environment.

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Kwashiorkor

A. Check levels of protein, albumin, prealbumin, and other nutritional laboratory measures

The key to the correct diagnosis in this case is recognizing edema, exfoliative dermatitis, and pigmentary dilution in an irritable child who consumes a relatively protein-deficient diet. This can be confirmed via laboratory evaluation revealing low levels of prealbumin, albumin, and total protein, as identified in this patient (prealbumin, 11 mg/dL; albumin, 1.7 g/dL; total protein, 3.8 g/dL) (choice A). Obtaining a urinalysis (choice B) is incorrect, as the edema of kwashiorkor is not secondary to protein loss in urine. The histologic features of kwashiorkor are not unique, and biopsy is not required for diagnosis (choice C).13 Kwashiorkor may be mistaken for atopic dermatitis or precipitated by well-intentioned parents who restrict their child’s nutrition in an effort to treat the condition.4 While topical steroids (choice D) may improve the dermatitis of kwashiorkor, this would not address the underlying cause.

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Article Information

Corresponding Author: Markus Boos, MD, PhD; Seattle Children’s Hospital, 4800 Sand Point Way NE, OC.9.833, Seattle, WA 98105 (markus.boos@seattlechildrens.org).

Published Online: January 7, 2021. doi:10.1001/jama.2020.10429

Conflict of Interest Disclosures: None reported.

Additional Information: We thank the patient’s mother for providing permission to share the patient’s information.

References
1.
Liu  T , Howard  RM , Mancini  AJ ,  et al.  Kwashiorkor in the United States: fad diets, perceived and true milk allergy, and nutritional ignorance.   Arch Dermatol. 2001;137(5):630-636.PubMedGoogle Scholar
2.
Guidelines for the Inpatient Treatment of Severely Malnourished Children. World Health Organization. Published 2003. Accessed July 22, 2020. https://www.who.int/nutrition/publications/guide_inpatient_text.pdf
3.
Brewster  DR .  Critical appraisal of the management of severe malnutrition, 2: dietary management.   J Paediatr Child Health. 2006;42(10):575-582. doi:10.1111/j.1440-1754.2006.00932.xPubMedGoogle ScholarCrossref
4.
Henrique de S B Xavier  M , De Magalhães  E , Ferraz Oliveira  G , Keltke Magalhães  M , Prates de Almeida E Oliveira  C , Bragança Oliveira  N .  A child with kwashiorkor misdiagnosed as atopic dermatitis.   Dermatol Online J. 2017;23(5):23(5):13030/qt4dd7h96r.PubMedGoogle Scholar
5.
Grover  Z , Ee  LC .  Protein energy malnutrition.   Pediatr Clin North Am. 2009;56(5):1055-1068. doi:10.1016/j.pcl.2009.07.001PubMedGoogle ScholarCrossref
6.
Katz  KA , Mahlberg  MJ , Honig  PJ , Yan  AC .  Rice nightmare: kwashiorkor in 2 Philadelphia-area infants fed Rice Dream beverage  [published correction appears in J Am Acad Dermatol. 2005;53(3):496].  J Am Acad Dermatol. 2005;52(5)(suppl 1):S69-S72. doi:10.1016/j.jaad.2004.07.056PubMedGoogle ScholarCrossref
7.
Sandy  NS , Nogueira  RJN .  Nutritional treatment of a young infant with cystic fibrosis presenting with severe kwashiorkor dermatosis.   J Trop Pediatr. 2019;65(6):634-637. doi:10.1093/tropej/fmz008PubMedGoogle ScholarCrossref
8.
Tierney  EP , Sage  RJ , Shwayder  T .  Kwashiorkor from a severe dietary restriction in an 8-month infant in suburban Detroit, Michigan: case report and review of the literature.   Int J Dermatol. 2010;49(5):500-506. doi:10.1111/j.1365-4632.2010.04253.xPubMedGoogle ScholarCrossref
9.
Downie  ML , Gallibois  C , Parekh  RS , Noone  DG .  Nephrotic syndrome in infants and children: pathophysiology and management.   Paediatr Int Child Health. 2017;37(4):248-258. doi:10.1080/20469047.2017.1374003PubMedGoogle ScholarCrossref
10.
Brewster  DR .  Critical appraisal of the management of severe malnutrition, 3: complications.   J Paediatr Child Health. 2006;42(10):583-593. doi:10.1111/j.1440-1754.2006.00933.xPubMedGoogle ScholarCrossref
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