Kwashiorkor — DTM&H MCQ

Correct answer: C — Kwashiorkor

The correct answer is C, Kwashiorkor. This child has bilateral pitting oedema, the pathognomonic sign of nutritional (oedematous) malnutrition, together with hypoalbuminaemia (18 g/L), flaky paint dermatosis, and a fatty, enlarged liver, the classic tetrad of kwashiorkor. Kwashiorkor arises from relative protein deficiency in the context of adequate or near adequate calorie intake, causing hypoalbuminaemia driven oedema, skin and hair changes, and hepatic steatosis. The MUAC of 120 mm alone (above the 115 mm SAM cutoff) would not indicate severe acute malnutrition, but WHO criteria state that bilateral oedema alone is sufficient to classify a child as having severe acute malnutrition regardless of MUAC or weight for height. The presence of oedema with these systemic features, rather than pure wasting, is what defines kwashiorkor over other options. Why the other options are wrong: E. Marasmus: This is severe wasting from combined protein and calorie deficiency with visible severe wasting but no oedema; the presence of bilateral pitting oedema excludes marasmus by definition. D. Congestive cardiac failure: This would cause oedema but does not explain the flaky paint dermatosis, hepatomegaly with fatty infiltration, or profound hypoalbuminaemia in a malnourished child, and there is no history of cardiac symptoms or signs given. B. Marasmic-kwashiorkor: This requires evidence of significant wasting (very low MUAC or weight for height with visible severe muscle wasting) alongside oedema; the MUAC here is 120 mm, above the severe wasting threshold, so wasting is not demonstrated. A. Nephrotic syndrome: This causes hypoalbuminaemia and oedema but is a renal cause unrelated to the setting described and does not account for flaky paint dermatosis or the dietary context typical of kwashiorkor in this region. Key point: Bilateral pitting oedema plus hypoalbuminaemia, dermatosis and hepatomegaly, without severe wasting on MUAC, defines kwashiorkor as a distinct oedematous form of severe acute malnutrition.

Reference: WHO, Guideline: Updates on the Management of Severe Acute Malnutrition in Infants and Children, 2013 (Executive summary): https://www.ncbi.nlm.nih.gov/books/NBK190325/