A 2-year-old boy from rural Maharashtra is brought to the pediatric clinic by his mother with a 6-month history of poor weight gain and recurrent infections. On examination, he weighs 10 kg (50th percentile for age is 13 kg), height 82 cm, and appears apathetic with sparse, thin hair that plucks easily. Skin turgor is normal, and there is no pitting edema. Serum albumin is 3.2 g/dL (normal >3.5), and hemoglobin is 9.8 g/dL. The child has been exclusively on a diet of rice and lentils with minimal animal protein. What is the most likely diagnosis?

Explanation

## Clinical Diagnosis: Marasmus ### Key Distinguishing Features **Key Point:** Marasmus is characterized by chronic protein-energy deficiency with wasting, preserved serum albumin (relatively), and absence of edema. This child presents with: - Severe wasting (weight-for-age <50% of expected) - Normal skin turgor (no pitting edema) - Apathy and sparse, thin hair (sign of chronic malnutrition) - Relatively preserved serum albumin (3.2 g/dL, mild reduction) - History of inadequate total caloric and protein intake ### Comparison of PEM Subtypes | Feature | Marasmus | Kwashiorkor | Marasmic Kwashiorkor | |---------|----------|-------------|---------------------| | **Protein intake** | ↓↓ | ↓ (relative) | ↓↓ | | **Calorie intake** | ↓↓ | ↓ (relative) | ↓↓ | | **Weight loss** | Severe (>60% expected) | Moderate | Severe | | **Edema** | Absent | Present (bilateral, pitting) | Present | | **Serum albumin** | Low-normal to low | Very low (<2.0) | Very low | | **Hair changes** | Sparse, thin, dull | Sparse, thin, reddish | Sparse, thin, reddish | | **Skin turgor** | Poor | Normal/good | Poor | | **Appearance** | "Old man look" | Moon face, pot belly | Mixed features | **High-Yield:** Marasmus = **wasting without edema**; Kwashiorkor = **edema with relatively preserved weight**. ### Pathophysiology 1. Chronic caloric deficit → mobilization of muscle and adipose tissue 2. Preserved hepatic protein synthesis (albumin) due to maintained gluconeogenesis 3. Absence of acute stressor that precipitates kwashiorkor 4. Apathy and hair changes reflect micronutrient deficiencies (iron, zinc, vitamin A) **Clinical Pearl:** The "old man look" (wizened face, prominent ribs, loose skin folds) is pathognomonic for marasmus and reflects severe muscle wasting. ### Management Principles - **Gradual refeeding** (avoid refeeding syndrome) - Micronutrient supplementation (iron, zinc, vitamin A, B vitamins) - Treat concurrent infections - Dietary counseling on protein-rich foods (eggs, milk, legumes) [cite:IAP Textbook of Pediatrics Ch 8]