Prothrombin time as an index of mortality in kwashiorkor

Prothrombin time, serum albumin, aminotransferases and liver size were evaluated in 40 consecutive cases of kwashiorkor. Eleven (27.5%) of the 40 patients died. Eight out of the 11 patients who died had a prolonged prothrombin time of more than 3 s above the control compared to only 4 out of the 29 who survived (p = 0.005). Mean serum aspartate aminotransferase (AST), alanine aminotransferase (ALT) albumin, globulin and liver size were abnormal but similar in both groups. These results may indicate a predictive mortality value of prothrombin time in kwashiorkor.

[Kinetics of in vitro proliferation of lymphocytes from malnourished children]

Lymphocytes from five severely malnourished children were cultured with bromodeoxyuridine (BrdU) and stained by the differential sister chromatid procedure using cells harvested at 48, 60, 72, 84 and 96 hours of incubation. Our results show that from 48 to 84 hours, the proportion of cells going from first to second and second to third generation cycles are higher than those cells from well-nourished children used as controls. The most dramatic difference between groups was seen at 48 hours: the proportion of first cycle metaphases was 63% and those in second cycle were 36% in the malnourished children, whereas the control group showed mainly first cycle metaphases (96%) and few (4%) had gone through the second cycle. Mathematical analysis of first cycle metaphase kinetics indicates that in the well-nourished group, 100% of the metaphases were in first cycle after 43.6 hours of culture, whereas in the malnourished group the second cycle metaphases began to appear at 36.5 hours of culture. The analysis for the third kinetics showed that the time of appearance of these cells was 8 hours earlier in the malnourished group than in the control group. These results are controversial because some authors have reported delay in the cell cycle duration. Murthy et al studying lymphocytes in vitro from children with Kwashiorkor found that the extent of this increase was 4.5 hours for the first-division cells and 1.5 hours for third division cells. However, Mutchinick et al studying nine children with severe protein malnutrition, report that the proportion of 3rd or subsequent division metaphases was higher than that seen in the control group. Our results agree with them in terms of early appearance of 3rd cycle cells.

Effect of kwashiorkor on the cardiovascular system

In kwashiorkor the heart is clinically and radiologically small. This study utilises echocardiography, a tool not previously used in this disease, to show that this is due to decreased muscle mass.

Ultrastructure and cell cycle distribution of bone marrow cells in protein-energy malnutrition

Bone marrow aspirates from four children with kwashiorkor and three with marasmus were studied using the techniques of electron microscopy and combined Feulgen microspectrophotometry and 3H-thymidine autoradiography. The majority of the erythroblasts were ultrastructurally normal, the distribution of the early polychromatic erythroblasts between the various stages of the cell cycle was normal or almost normal, and the macrophages did not contain ingested erythroblasts. Since erythropoietin production has been shown to be normal in protein-energy malnutrition, these findings suggest that at least in some cases of PEM the impairment of erythropoiesis results primarily from an abnormality in the erythroid progenitor cell pool rather than from dyserythropoiesis and ineffective erythropoiesis. In one afebrile and apparently uninfected patient with marasmus, a substantial proportion of the neutrophil granulocytes and their more mature precursors contained electron-dense, myelin-containing intracytoplasmic structures which were presumed to be abnormal primary granules. In four of the patients, the 3H-thymidine labelling index of the neutrophil promyelocyte-myelocyte pool was increased. In addition, in all of the cases, neutrophils at various stages of degradation were readily found within the cytoplasm of some of the macrophages. Thus, whereas the techniques employed did not reveal a major disturbance in the morphologically recognizable precursor cells of the erythroid series in PEM, they demonstrated some abnormalities in such cells of the neutrophil series.

Skin in protein energy malnutrition

Protein energy malnutrition (PEM), the most widespread nutritional deficiency disorder of mankind, is a group of related disorders, with a more complex and still incompletely understood etiologic basis than its name suggests. Dermatologic and other clinical manifestations are more florid and characteristic in kwashiorkor than in marasmus. The complex of clinical syndromes that constitute PEM is best considered when using a three-dimensional model to illustrate its varying degrees (ie, mild, moderate, or severe) and the spectrumlike nature of the forms of the severe degree (ie, kwashiorkor, marasmic-kwashiorkor, or marasmus). Protein energy malnutrition is not confined to children in the Third World and is the most common form of undernutrition in hospitalized patients in Western countries. Marasmus is by far the most prevalent form. Much of the nutritional support given in hospitals is not based on an assessment of nutritional status, and little attention is paid to the different forms PEM might take. Even those who do consider this last point confuse hypoalbuminemia in patients acutely stressed or infected with kwashiorkor. Recent evidence suggests that the skin changes of kwashiorkor may be caused by zinc deficiency. Almost nothing is known about the histopathology of the skin per se in PEM but studies of the hair bulb have shown important differences among patients with kwashiorkor, marasmus, and normal skin.

Bone and soft tissue components of the leg in infants with protein calorie malnutrition

The measurements of muscle, fat and cortical thickness were made on leg radiographs of 40 kwashiorkhor infants and were compared with those of 32 normal infants. There is a significant decrease in muscle cylinder ratio, an index of the contribution of muscle to calf thickness in kwashiorkhor. The loss of bone cortex in kwashiorkhor is due mainly to failure of appositional growth. The muscle cylinder ratio in normal Nigerian infants is much higher than has been reported amongst Caucasians.

Fifty years ago. Archives of Diseases in Childhood 1933. A nutritional disease of childhood associated with a maize diet

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Kwashiorkor: an electron histochemical study of the hair shaft

Previous studies on hair in kwashiorkor have been equivocal regarding the normal or abnormal incorporation of amino acids into the hair shaft. In this study we have applied a sensitive electron histochemical technique to transverse sections of scalp hair from children with severe kwashiorkor in order to study its ultrastructure and the incorporation of sulphur-containing amino acids (cystine). We have found no evidence to support the idea that a protein deficient diet in the weaning or post-weaning period directly affects the distribution and relative amounts of sulphur-containing amino acids in the hair shaft in this disease.

Histopathological changes in the temporal bone in kwashiorkor

The histopathological changes in human temporal bones are described for 2 cases of kwashiorkor--a protein/calorie malnutrition (PCM) state. There is photographic evidence of severe damge to the middle and inner ears and to the vestibulocochlear nerve. The middle ear shows evidence of chronic otitis media, a common clinical finding in kwashiorkor. Significantly, the round window membranes in both cases showed thickening and infiltration with inflammatory cells. The inner ear showed the loss of cellular elements and hair cell loss in the spiral organ. A marked decrease of spiral ganglion cells and demyelination of the vestibulocochlear nerve were also seen.

Infantile jejunal mucosa in infection and malnutrition

Sixteen children with refractory diarrhea and three malnourished children who had frequent episodes of acute gastroenteritis but little diarrhea at the time of hospital admission, were studied by peroral upper small intestinal biopsy. Six children were adequately nourished; five children weighed 62 to 79% of expected weight and eight weighed less than 60% of expected weight. Two of the malnourished children had giardiasis. Pathogenic bacteria were found in only one case. Varying degrees of mucosal atrophy with reduction of mean villous height were seen in 18 cases. The concentration of mononuclear inflammatory cells and plasma cells was about half that seen in well-nourished children with severe nongastrointestinal infections. The concentration of mononuclear cells in the lamina propria was about twice that seen in normal adults. The proportions of IgA-producing cells and cells that stained for secretory component were significantly reduced, as compared with normal adult control values. This reduction was most striking in children with malnutrition complicated by giardiasis. Enzyme histochemical studies were performed for leucine aminopeptidase, alkaline phosphatase and acid phosphatase. There was a tendency for considerably reduced acid phosphatase activity in all clinical groups (kwashiorkor, marasmic kwashiorkor and marasmus) of growth-retarded infants.

Fat embolism in kwashiorkor

Fat embolism from the grossly fatty liver of an infant with kwashiorkor is described. Globules of fat were seen at necropsy in the hepatic veins, in the right atrium and ventricle of the heart and in the pulmonary artery. Sections of the lung showed fat emboli in numerous branches of the pulmonary artery. Examination of lung sections taken at necropsy from 40 patients who had severe kwashiorkor failed to show similar fat embolism.

Nutritional disturbances of protein metabolism in the liver

Nutritional disturbances of protein metabolism in the liver are reviewed in relation to feeding experimental animals the following diets: a) purified diets deficient in amino acids; b) amino acid mixtures or single amino acids; c) protein-free (amino acid-free) diets; or d) hypertonic or hypotonic solutions. The effects of tube-feeding the diets or dietary components for days, hours, or minutes on hepatic polyribosomes and protein synthesis are described. Force-feeding a purified diet free of single essential amino acids induces within days morphologic changes resembling those that occur in humans with kwashiorkor, a world-wide nutritional deficiency disease in children. In this kwashiorkor-like model, hepatic protein synthesis and polyribosomal aggregation are increased. Administration of a complete amino acid mixture or tryptophan alone, but no other single amino acid, produces a rapid stimulation (within minutes) of hepatic protein synthesis and polyribosomal aggregation in animals that had been fasted, fed, or treated with hepatotoxic agents. A single tube-feeding of a protein-free (amino acid-free) diet induces within hours an increase in hepatic protein synthesis in fasted animals. Administration of hypertonic solutions rapidly (within minutes) inhibits, while administration of hypotonic solutions rapidly increases, hepatic protein systhesis. These experimental findings are reviewed in terms of how alterations in regulatory controls of hepatic protein synthesis may be influenced by nutritional disturbances. Such information may be of importance in designing and utilizing nutritional approaches in the therapy of liver diseases.

Neutrophil function in children with kwashiorkor

Peripheral blood polymorphonuclear neutrophil (PMN) function has been investigated for 46 children with kwashiorkor (without overt infection) in the Ivory Coast, West Africa. In vitro chemotactic response, candidacidal activity, and kinetic studies of metabolism during phagocytosis have been performed. Postphagocytic morphological events were evaluated by electron microscopy. The reduction of nitroblue tetrazolium (NBT), measurement of enzyme activities, activity of glycolysis, and hexose monophosphate shunt (HMS) activity were assessed. The extent of iodide incorporation into trichloracetic acid (TCA)-precipitable protein by phagocytizing PMN'S and thyroid hormone degradation were measured. Chemotactic response was reduced at early time intervals (30, 60, and 120 minutes) and reached control values after 180 minutes. Whereas PMN's of controls killed 32.13 +/- 11.10 per cent of Candida albicans after 60 minutes, PMN's from kwashiorkor patients killed 18.55 +/- 7.74 per cent (p less than 0.01). HMS activity for resting PMN's of kwashiorkor children was higher than for controls, and during particle ingestion the extent of stimulation was comparable to controls. Electron microscopic assessment of phagocytic vacuole formation and degranulation showed no difference between PMN's from kwashiorkor and and control subjects. Incorporation of 131 I into TCA-precipitable proteins by phagocytizing PMN's from kwashiorkor children was reduced in compraison to controls, with either viable or heat-killed lactobacilli. No impairment in thyroxine (T4) degradation was observed for PMN's from kwashiorkor cases. PMS's from kwashiorkor patients show toxic granules, Dohle bodies, evidence of high baseline NBT reduction, and glucose decarboxylation. Functional studies indicate impaired kinetics of chemotaxis, diminished candidacidal activity, and reduced iodination. Enzymatic activities of resting cells are normal. Lactate production, HMS activity during phagocytosis, and morphological events are not impaired. Thus, impaired in vitro microbicidal activity, increased resting metabolism, and decreases iodination by PMN's may be related to the high incidence of infection in kwashiorkor.