Marasmus — DTM&H MCQ

Correct answer: D — Marasmus

The correct answer is D, Marasmus. This child shows the classic phenotype of severe wasting (visible ribs, loss of buttock fat, alertness with irritability) without oedema, which defines non-oedematous severe acute malnutrition (marasmus) rather than the oedematous form (kwashiorkor). WHO guidance used across UK tropical medicine training defines severe acute malnutrition by the presence of oedema of both feet or severe wasting, and specifically notes that marasmus is the wasting form driven by prolonged energy and protein deficiency with catabolism of fat and muscle. The absence of oedema, the preserved but irritable mental state, and poor appetite (an important triage sign for admission) all point away from kwashiorkor and toward marasmus. Poor appetite here also signals that this child needs inpatient stabilisation rather than outpatient ready-to-use therapeutic food. Why the other options are wrong: C. Kwashiorkor: defined by bilateral pitting oedema, often with skin and hair changes and a rounded moon face; this child explicitly has no oedema, excluding it. B. Wet beriberi: caused by thiamine deficiency and presents with high-output cardiac failure and oedema, not the fat and muscle wasting pattern described. E. Pellagra: due to niacin deficiency, producing the classic triad of dermatitis, diarrhoea and dementia; there is no mention of skin lesions or gastrointestinal or neurological features here. A. Vitamin A toxicity: causes raised intracranial pressure, skin desquamation and hepatotoxicity, not a wasting syndrome, and is unrelated to the clinical picture given. Key point: severe wasting without oedema is marasmus, while bilateral pitting oedema (with or without visible wasting) defines kwashiorkor, and this distinction (not appetite or mental state alone) is what separates the two forms of severe acute malnutrition.

Reference: WHO Pocket Book of Hospital Care for Children, chapter on Severe Acute Malnutrition (NCBI Bookshelf NBK154454), https://www.ncbi.nlm.nih.gov/books/NBK154454/