Marasmus and TB

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younger than 4 years. This period is characteri5ed by increased energy re0uirements and

increased susceptibility to viral and bacterial in#ections.6eaning the deprivation o# breast mil'

and the commencement o# nourishment with other #ood! occurs during this high(ris' period.

6eaning is o#ten complicated by geography$ economy$ hygiene$ public health$ culture$ and

dietetics.

Pulmonary tuberculosis is an in#ectious disease caused byMycobacterium tuberculosis. "n

many cases$M tuberculosisbecomes dormant be#ore it progresses to active T7. "t most

commonly involves the lungs and is communicable in this #orm$ but may a##ect almost any organ

system including the lymph nodes$ C8S$ liver$ bones$ genitourinary tract$ and gastrointestinal

tract 9orne$ ,-!.

Transmission o#M. tuberculosis is person to person$ usually by airborne mucus droplet

nuclei$ particles (4 ; m in diameter that containM. tuberculosis. Transmission rarely occurs by

direct contact with an in#ected discharge or a contaminated #omite. The chance o# transmission

increases when the patient has a positive acid(#ast smear o# sputum$ an e


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C9APT)R ,

1"T)RAT?R) R)@")6

,. Marasmus

e#inition

Marasmus is one o# the #orms o# serious protein(energy malnutrition P)M!. The other , #orms

are 'washior'or K6! and marasmic K6. These #orms o# serious P)M represent a group o#

pathologic conditions associated with a nutritional and energy de#icit occurring mainly in young

children #rom developing countries at the time o# weaning. Marasmus is a condition primarily

caused by a de#iciency in calories and energy$ whereas 'washior'or indicates an associated

protein de#iciency$ resulting in an edematous appearance. Marasmic 'washior'or indicates that$

in practice$ separating these entities conclusively is di##icult& this term indicates a condition that

has #eatures o# both Rabinowit5 et al$ ,->!.

)tiology

P)M$ unli'e the other important nutritional de#iciency diseases$ is a macronutrient de#iciency$not a micronutrient de#iciency. Although termed P)M$ it is now generally accepted to stem in

most cases #rom energy de#iciency$ o#ten caused by insu##icient #ood inta'e. )nergy de#iciency is

more important and more common than protein de#iciency. "t is very o#ten associated within#ections and with micronutrient de#iciencies. "nade0uate care$ #or e


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inappropriate use o# in#ant #ormula in place o# breast#eeding #or very young in#ants in

poor #amilies&

staple diets that are o#ten o# low energy density not in#re0uently bul'y and

unappeti5ing!$ low in protein and #at content and not #ed #re0uently enough to children&

inade0uate or inappropriate child care because o#$ #or e!$ nearly -E o# humans currently e


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Pathophysiological changes associated with nutritional and energy de#icits can be described as

! body composition changes$ ,! metabolic changes$ and ! anatomic changes Rabinowit5 et

al$ ,->!.

7ody Composition Changes

7ody mass: 7ody mass is signi#icantly decreased in a heterogeneous way.

Dat mass: Dat stores can decrease to as low as 4E o# the total body weight and can be

macroscopically undetectable. The remaining #at is usually stored in the liver$ giving a

parado


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7ecause arm circum#erence is relatively constant in healthy children aged (4 years$ it

roughly represents a general assessment o# nutritional status.

Metabolic Changes

Potassium: Potassium is the electrolyte most studied in marasmus. Total body potassiumde#icit is associated with decreased muscle mass$ poor inta'e$ and digestive losses. This

potassium de#icit$ which can reach 4 m)0G'g$ contributes to hypotonia$ apathy$ and

impaired cardiac #unction.

+ther electrolytes: Plasma sodium concentration is generally within the re#erence range$

but it can be low$ which is then a sign o# a poor prognosis. 9owever$ intracellular sodium

level is elevated in the brain$ muscle$ and red and white blood cells$ e


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Metabolic Changes

The overall metabolic adaptations that occur during marasmus are similar to those in starvation$

which have been more e-E in severe #orms!$ and protein(sparing mechanisms regulated by compleB >

1ETABO,$?1E @A9BOH$D9AT

&lukosa darah (sewaktu) mgGd1 -.,- ,--

&$!>A,

:reum mgGd1 4.B- 4-

@reatinin mgGd1 -., -.( -.>

Asam :rat mgGd1 .3 .-

Elektrolit

!atrium (!a) m)0G1 2 4( 44

@alium (@) m)0G1 .3 .2( 4.4

@lorida (#l) m)0G1 -4 B2( -2

'ollow up- 4thApril 23/4

S: Dever (!$ Cough (!

+: Sense: CM T: UC

9ead: )yes 1R VGV!$ isochoric pupil$ pale in#erior palpebral con%unctiva (!$ )G8GM: 8

8ec': 18 enlargement V!

Thora


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Cetiri5in syr < cth

iet M7 --- ''alV D-- < ,--cc V Mineral mi< >.-cc

#HATE9 4

D$?#:??$O! A!D ?:11A9;

Marasmus is a type o# protein energy malnutrition. "t is characteri5ed by old man #ace$ the

thinning o# the subcutaneous #at layer$ baggy pants$ altered mental state$ muscle atrophy and

easily seen rib bones.

Pulmonary tuberculosis is an airborne in#ection caused by the bacteria Mycobacterium

tuberculosis. "t most commonly a##ects the lungs but it can attac' any part o# the body including

the 'idneys$ spine and brain. Some o# the symptoms o# tuberculosis in#ection are cough lasting

more than wee's$ coughing up blood or sputum$ pain in the chest$ wea'ness or #atigue$ weight

loss$ no appetite$ chills$ #ever and sweating at night.

Patient R6 came to Adam Mali' Ieneral 9ospital with the main complaint o# decreasing bodyweight. Patient R6 has e


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@itamin A was given to the patient as de#iciency a##ects visual #unction eg. con%unctivitis and

night blindness! and digestive$ respiratory and urinary #unctions. Multivitamin without iron also

was administered because in the most serious #orm o# marasmus$ iron accumulates in the liver$

most li'ely because o# the de#icit in transport protein.

Rimcure Paed is the antibiotic prescribed #or the pulmonary tuberculosis. "ts composition isRi#ampicin 4 mg$ "sonicotine hydra5ine 4- mg and Pyra5inamide 4- mg. Rimcure Paed 'ills

or stops the growth o# bacteria that causes tuberculosis.

Ampicillin was administered at #irst to treat bronchopneumonia. Ampicillin belongs to the class

o# antibiotics called penicillin that are used to treat bacterial in#ections. "t stops bacteria #rom

multiplying by preventing bacteria #rom #orming the walls that surround them.

As the patient was diagnosed with miliaria$ he was given cetiri5ine which is a non( sedating

antihistamine that wor's by bloc'ing histamine 9( ! receptors on cells. 9istamine is released

#rom histamine( storing cells mast cells! and then attaches to other cells that have receptors #orhistamine. The attachment o# the histamine causes the cells to be YactivatedW$ releasing other

chemicals that produce the e##ects that we associate with allergy.

Dolic acid was given to treat or prevent #olic acid de#iciency. "t is a 7(comple< vitamin needed

by the body to manu#acture red blood cells. A de#iciency o# this vitamin causes certain types o#

anemia.


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R)D)R)8C)S

Ashworth$ A. ,--!. !uidelines "or the in#atient treatment o" se$erely malnourished children.

st ed. Ieneva$ Swit5erland: 6orld 9ealth +rgani5ation.

9erchline$ T. and Amorosa$ *. ,->!. Tuberculosis. Jonline )medicine.medscape.com.

Available at: http:GGemedicine.medscape.comGarticleG,-3-,(overview[showall JAccessed ,,

Apr. ,->.

9orne$ . ,-!.Pulmonary Tuberculosis. Jonline 7M* 7est Practice. Available at:

http:GGbestpractice.bm%.comGbest(practiceGmonographG24GbasicsGde#inition.html JAccessed ,,

Apr. ,->.

*amabo$ T. and +nwu'we$ A. ,--!. The "ncidence o# Marasmic(Kwashior'or Among Children

in Port 9arcourt$ 8igeria.Nigerian %ournal o" &griculture, Food and 'n$ironment$ Jonline 2

\ >!$ pp.B2(--. Available at: http:GGn%a#e.orgG8%a#e,--@ol28o]>G*AMA7+.pd#.

Kliegman$ R. and 8elson$ 6. ,-!.Nelson textboo( o" #ediatrics. st ed. Philadelphia$ PA:

)lsevierGSaunders.

1atham$ M. BB!.)uman nutrition in the de$elo#ing *orld. st ed. Rome: Dood and

Agriculture +rgani5ation o# the ?nited 8ations.

1eung$ A. BBB!. Pulmonary Tuberculosis : The )ssentials.R+N&$ Jonline ,-,!$ pp.-(,,.

Available at:


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http:GGwww.med.uottawa.caGradiologyGassetsGdocumentsGchest]cardiac]imagingGarticlesGthe

E,-essentialE,-o#E,-T7.pd#.

+rgani5ation$ 6. ,-!.Poc(et oo( o" )os#ital Care "or Children. st ed. Ieneva: 6orld

9ealth +rgani5ation.

Rabinowit5$ S.$ Iehri$ M.$ i Paolo$ ).$ 6etterer$ 8. and Prince$ ). ,->!.Marasmus. Jonline

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overview[showall JAccessed Apr. ,->.

Schein#eld$ 8.$ Mo'ashi$ A. and 1in$ A. ,-,!.Protein-'nergy Malnutrition. Jonline

)medicine.medscape.com. Available at: http:GGemedicine.medscape.comGarticleG->2,(

overview[showall JAccessed ,, Apr. ,->.

Star'e$ *. ,-->!. Tuberculosis in Children. +eminars in Res#iratory and Critical Care Medicine$

Jonline ,4!. Available at: http:GGwww.medscape.comGviewarticleG>3>,], JAccessed ,, Apr.

,->.

6ho.int$ ,->!. ) / Tuberculosis 0T1. Jonline Available at:

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6orld Dood Programme and the Centers #or isease Control and Prevention$ ,--4!.& Manual :

Measuring and nter#reting Malnutrition and Mortality. Rome: ?89CR.

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