Computed tomography of the brain in kwashiorkor: a follow up study

Refeeding Syndrome Developed in a Patient With Kwashiorkor Can Mimic Findings of Mitochondrial Disorder

Kwashiorkor is a serious nutritional disease. The 7-month-old male patient presented with severe metabolic acidosis and elevated liver enzymes. His condition was similar to fatty acid oxidation defect. He was taken to the hospital on the previous day with complaints of poor sucking and difficulty breathing. Treatment of upper respiratory tract infection was provided and then he returned to his home. He was cyanotic in bed after 12 hours. The patient, who was taken to the hospital unconscious and not fed for 12 hours, was not given any food orally in the first health center. Until laboratory tests are done, only iv electrolyte and a fluid containing dextrose were given. When the laboratory results were found to be significantly pathological, he was urgently referred to our hospital 4 hours after the admission. The content of the iv treatment applied at the time of referral was not clearly written. Low electrolytes, uric acid, liver enzymes, urea and creatinine elevation were detected at an outer center. Ketosis, lactic acidosis and dibasic aciduria were detected in urine organic acid analysis. He was diagnosed with Kwashiorkor and refeeding syndrome according to the clinical and laboratory findings. His complaints improved with appropriate treatment.

Brain MRI and cognitive function seven years after surviving an episode of severe acute malnutrition in a cohort of Malawian children

Objective

To assess differences in cognition functions and gross brain structure in children seven years after an episode of severe acute malnutrition (SAM), compared with other Malawian children.

Design

Prospective longitudinal cohort assessing school grade achieved and results of five computer-based (CANTAB) tests, covering three cognitive domains. A subset underwent brain MRI scans which were reviewed using a standardized checklist of gross abnormalities and compared with a reference population of Malawian children.

Setting

Blantyre, Malawi.

Participants

Children discharged from SAM treatment in 2006 and 2007 (n 320; median age 9·3 years) were compared with controls: siblings closest in age to the SAM survivors and age/sex-matched community children.

Results

SAM survivors were significantly more likely to be in a lower grade at school than controls (adjusted OR = 0·4; 95 % CI 0·3, 0·6; P < 0·0001) and had consistently poorer scores in all CANTAB cognitive tests. Adjusting for HIV and socio-economic status diminished statistically significant differences. There were no significant differences in odds of brain abnormalities and sinusitis between SAM survivors (n 49) and reference children (OR = 1·11; 95 % CI 0·61, 2·03; P = 0·73).

Conclusions

Despite apparent preservation in gross brain structure, persistent impaired school achievement is likely to be detrimental to individual attainment and economic well-being. Understanding the multifactorial causes of lower school achievement is therefore needed to design interventions for SAM survivors to thrive in adulthood. The cognitive and potential economic implications of SAM need further emphasis to better advocate for SAM prevention and early treatment.

Executive functions of postweaning protein malnutrition in mice

It is well known that nutritional status during the fetal and/or lactation period is important for the development of the central nervous system (CNS). In contrast, the effect of malnutrition on postweaning development has not yet been thoroughly investigated. In the present study, we analyzed the behavioral and neuroanatomical effects of protein malnutrition (PM) postweaning in mice. Starting at 20-21 d of age, male ddY mice were maintained on a 5% casein diet (PM group) or 20% casein diet (control group) for 20 d. On the 20th d, body and brain weights of PM mice were lower than those of the control group. PM mice exhibited excessive alertness and spontaneous activity under novel conditions in the Irwin test. In addition, PM mice showed increased open arm exploration in the elevated plus maze compared to control mice. These results suggest that hyperactivity and reduced anxiety behavior or higher impulsiveness in PM mice could be due to an immature brain.

THE MYELINATION PROCESS IN SEVERELY MALNOURISHED CHILDREN: MRI FINDINGS

This study reports cranial magnetic resonance imaging (MRI) findings in children with severe protein energy malnutrition (PEM) performed to determine malnutrition related myelination delay. A total of 20 children aged 2 months to 24 months were included in this study. Eleven (55%) of the children had severe wasting, five (25%) children had edematous malnutrition, and four (20%) children had severe stunting. The MRI findings of two (10%) children, both with severe stunting, indicated myelination delay according to Barkovich et al. (2000) and van der Knaap and Valk criteria 2005. Seventeen (85%) children also had MRI findings of cerebral atrophy. Conclusions indicate that the brain myelination process in the first two years of life of severely malnourished infants, as assessed by MRI, does not show significant delay caused by the nutritional impact on the myelination process.

S100B in underweight and weight-recovered patients with anorexia nervosa

Anorexia nervosa (AN) commonly arises during adolescence, leading to interruptions of somatic and psychological development as well as to cortical atrophy and reductions of brain volume. While most brain changes shift towards normal with weight restoration, it is not certain whether they are related to the loss of brain cells, neuropil or merely due to fluid shifts. We measured S100B serum concentrations and psychometric characteristics in 34 patients with acute AN, 19 weight-recovered patients and 35 healthy control women (HCW). Plasma tryptophan and leptin levels were determined as markers for malnutrition and neuroendocrine adaptation to semi-starvation. Peripheral S100B concentrations of acute and former AN patients were not elevated and not statistically different from HCW. BMI, peripheral leptin levels and measures of psychopathology as well as executive cognitive functioning did not correlate with S100B. Plasma tryptophan was positively related to S100B. Our results are in line with our previous findings showing unaltered GFAP and NSE plasma levels in patients with acute AN. Together they do not support hypotheses comprising the degeneration of glial or neuronal cells to explain common signs of brain atrophy in patients with acute AN.

Brain tissue volume segmentation in patients with anorexia nervosa before and after weight normalization

OBJECTIVE

To examine whether gray and white matter volumes are preferentially reduced and cerebral spinal fluid (CSF) increased with starvation in patients with anorexia nervosa compared with healthy controls and to determine what changes occur with weight normalization.

METHOD

Whole intracranial volumes of patients and controls were segmented into gray matter, white matter, and CSF volumes and results compared. A subgroup of patients were rescanned after weight normalization.

RESULTS

Total white matter and several regional white matter volumes were significantly reduced and total and regional CSF volumes were significantly increased in patients versus controls whereas gray matter was not significantly reduced. Total and regional CSF volumes were significantly decreased in patients upon weight normalization whereas white and gray matter volumes increased.

DISCUSSION

These changes in brain tissue may be related to a variety of pathophysiologic mechanisms. We hypothesize that insulin-like growth factor-1 may be involved.

The computed axial tomography of the brain in protein energy malnutrition

Forty consecutive new cases of protein energy malnutrition were evaluated clinically and biochemically; in addition, the brain morphology was assessed by computed tomography within 24 hours of admission. Cerebral shrinkage was shown in six of 14 (42.9%) cases of marasmus, ten of 14 (71.4%) cases of kwashiorkor, and 11 of 12 (91.7%) cases of marasmic-kwashiorkor. Ventricular dilatation was demonstrated in 57.1% of marasmus cases, 71.4% of kwashiorkor cases and 91.7% of patients suffering from marasmic-kwashiorkor. However, none of the subjects studied showed any changes in the brain stem or cerebellum. Only ten returned 2 months after nutritional rehabilitation for repeat tomograms. None of these repeat tomograms showed any residual morphological changes. The study demonstrated that the brain is affected in all types of malnutrition, albeit in different proportions, but these changes are completely reversible.

Electrophysiological assessment of brain function in severe malnutrition

Brain function in 10 severely malnourished children and matched controls was assessed using spectral analysis of electroencephalographic responses to photic driving during slow-wave sleep. The percentage power in the classical EEG broad-band domains was derived from temporo-occipital records. The malnourished group (5-23 months old; z-score height-for-age -3.2 +/- 0.3, weight-for-height -2.5 +/- 0.3) were tested on admission and on discharge from hospital. No significant differences were found between admission and discharge. Significant differences were found between malnourished and control groups, in the alpha 1 band in the undriven EEG, and in the alpha/beta 1 power ratio while driving at 8 Hz. These electrophysiological abnormalities, persisting despite somatic rehabilitation, must be associated with the chronic rather than the acute aspects of malnutrition, and can index the deviation of brain function from normality.

Serial CT scanning in childhood tuberculous meningitis: prognostic features in 198 cases

Serial cranial computed tomographic (CT) scanning and intracranial pressure monitoring were performed on 198 children with stage II and III tuberculous meningitis. The aims of the study were to document the course of tuberculous hydrocephalus during medical and surgical treatment, as well as the prognostic significance of parenchymal changes in the brain as demonstrated by CT. Lumbar cerebrospinal fluid pressure was monitored continuously for a 1-hour period in all patients on admission and at weekly intervals in patients with communicating hydrocephalus for the 1st month of treatment. Cranial CT scanning was done on admission and repeated in survivors after 1 month and again after 6 months of antituberculous therapy. The raised intracranial pressure of 112 children with communicating hydrocephalus, as demonstrated by air-encephalography, was treated medically (with daily acetazolamide and furosemide) for 1 month. Thirty-one children with noncommunicating hydrocephalus were referred for immediate ventriculoperitoneal shunting. No significant difference was found in the eventual ventricular size or clinical outcome between the two treatment groups. Lumbar cerebrospinal fluid pressure changes in the children with communicating hydrocephalus closely followed changes in the degree of hydrocephalus during the course of treatment. The main cause of permanent neurologic disability was basal ganglia infarction, which occurred unilaterally in 21% and bilaterally in 10% of patients on admission and developed in a further 22% of children during treatment. A prominent subarachnoid space, which was seen on the CT scan of 36% of patients after the 1st month of treatment and which reverted to normal, probably relates to the poor nutritional state of these patients on admission.(ABSTRACT TRUNCATED AT 250 WORDS)

Reversible cerebral shrinkage in kwashiorkor: an MRI study

Protein energy malnutrition is associated with cerebral atrophy which may be detrimental to intellectual development. The aim of this study was to document the anatomical abnormalities which lead to the appearance of cerebral atrophy using magnetic resonance imaging (MRI) in the acute stage of kwashiorkor and to monitor changes during nutritional rehabilitation. Twelve children aged 6 to 37 months requiring admission to hospital for the treatment of kwashiorkor were studied. The children were evaluated clinically, biochemically, and by MRI of their brains on admission and 30 and 90 days later. Brain shrinkage was present in every child on admission. White and grey matter appeared equally affected and the myelination was normal for age. At 90 days, the cerebral changes had resolved in nine and improved substantially in the remainder, by which time serum proteins and weight for age were within the normal range. The findings of this study suggest that brain shrinkage associated with kwashiorkor reverses rapidly with nutritional rehabilitation.