Case Report: Marasmus

Mona Claudya110100341
Yujinee Devi 110100468
Supervisor:
dr. Hj. Tiangsa Sembiring, M.Ked (Ped), Sp.A(K)

49% of the
10.4 million
deaths in
children
<5years

Suspectible
to infection

Protein
Energy
Malnutrition

3 forms:
Marasmus
Kwashiorkor
Marasmickwashiorkor

70% of the
world's
malnourished
children live
in Asia

Diagnostic features:
Weight-for-length/height
< -3SD (severe wasted)
Mid-upper arm
circumference < 115 mm
Oedema of both feet

Treatment of PEM

Stabilization Phase
Transitional Phase
Rehabilitation Phase
Follow-up Phase

Objective

The aim of this study is to report a case of a 9 months

old boy with diagnosis of marasmus and gastrointestinal
bleeding

Case
AK, 9 months old boy was admitted on October, 15 th 2015 with
complaint of losing appetite and weight loss. It has been
occured since 2 months ago. Patient could never finished the
meal served. Patient also complain of having black stool. It was
experienced since 8 days before admission with frequency
twice a day, volume 2cc for each stool with watery consistency.
Vomitting (+) red-blackish colored 4 times with volume
100cc for each vomitting. Epistaxis (-), gum bleeding (-),
bruised on the body (-), other spontaneous bleeding (-). Fever
(+) since 10 days before admission, the temperature was not too
high and was decreased by anti-pyretic drug. Urinating system
was normal, with yellow clear in the color. During the
admission the fever was still occured.

 History of previous illness:

He had ever been hospitalized in Haji Adam Malik
Hospital on July 2015 when he was 6 months old for
the black stool diarrhea. After being discharged, he
never got to control and got any medication to doctor
for his illness. He suffered from recurrent black stool
in past 8 days.
History of immunization : not clear

 History of nutrition:
6 month of exclusive breast feeding, additional food since 6
months old
History of obstetric:
the mother was 38 years old when she was pregnant, no
history of consuming drugs and herbs, no history of having
DM and hypertension during pregnancy
History of growth and development:
At the moment, the patient could sit down with assistance

Physical Examination
General status
Body weight

4,9 kg

Body length

64 cm

Head circumference

45cm

Mid-upper arm circumference

9,5cm

Weight-for-age

z-scores < -3 SD

Length-for-age

z-scores < -3 SD

Weight-for-length

z-scores < -3 SD

Severe Malnutrition

Presence status
Consciousness
: alert
Blood Pressure : 90/40 mmHg
Heart Rate : 124 x/i
Respiratory Rate : 30 x/i
Body Temperature : 37,9 oC
Anemic (+) Icteric (-) Cyanosis (-) Edema (-)
Dyspnea (-)

Local Status
Head
old-man face, isochoric pupil, pale inferior palpebra
conjunctiva, light reflex on both eyes. Ears/ nose/ mouth:
within normal limit
Neck
No lymph node enlargement
Thorax
Symmetrical fusiformis, intercostal space clearly visible,
protruding spine. HR: 120x/i, regular, murmur (-). RR:
23x/i, regular, ronchi (-), breath sound: vesicular,
additional sound (-)

 Abdomen
Soepel, normal peristaltic, liver and spleen
unpalpable, skin pinch returns quickly
Extremities
Hypothrophy muscle, subcutaneous fat
thinning. Pulse 120x/i, regular, adequate
pressure and volume, warm, CRT < 3, no
pitting edema

Differential Diagnosis:
Marasmus + Gastrointestinal bleeding +
Haemmorhagic anemia
Marasmus + Gastrointestinal bleeding + Anemia
of chronic disease
Working Diagnosis:
Marasmus + Gastrointestinal bleeding +
Haemmorhagic anemia

Management:
IVFD D5% NaCl 0,225% 20gtt/i macro
Folic acid 1x5 mg
Vitamin A 1x 100.000 IU
Diet F75 80 cc/3 hours + 1,6 cc mineral mix
Inj Ceftriaxone 250 mg/12 hours/iv
Transfusion PRC 25 cc/12 hours

Diagnostic Planning:
Complete Blood Test
Urine and fesces analysis
Ferum Profile
Urine and Fesces Examination
Plain abdominal x-ray
Barium meal
Albumin

Laboratory Finding: October 15 th , 2015

Haematology

Result

Normal

7.00

11.1 14.4

Eritrocyte

2.43

3.71 - 4.25

Leucocyte

15.83

6.0 - 17.5

22.0

35 - 41

158

217 497

Haemoglobin

Haematocrite

g/dL

Thrombocyte
MCV

fL

90.50

82 - 100

MCH

pg

28.80

24 - 30

MCHC

g%

31.80

28 - 32

RDW

21.40

14.9 - 18.7

Neutrofil

66.30

37 - 80

Limphocyte

19.10

20 - 40

Monocyte

11.20

2-8

Eosinofil

3.30

1-6

Basofil

0.100

0-1

From the table above, we found anemia and thrombocytopenia.

Haemostasis
Prothrombin Time
Patient

Control

Result
seconds
seconds

INR
APTT
Patient

Control

Thrombin Time
Patient

Control

Normal

17.2
13.8
1,26

seconds
seconds

28.2
32.0

seconds
seconds

15.6
17.5

Clinical Chemistry

Result

Normal

Random Blood Glucose

g/dL

112.10

40-60

Ureum

mg/dL

15.80

<50

Creatinine

mg/dL

0.11

0.17-0.42

Haematocrite

13.5

37 - 41

Natrium (Na)

mEq/L

130

135-155

Kalium (K)

mEq/L

3.6

3.6 5.5

Chloride (Cl)

mEq/L

101

96-106

Urinalysis Complete Urine

Color
Glucose
Bilirubin
Keton
Spesific gravity
pH
Protein
Urobilinogen
Nitrit
Leucocyte
Blood
Urine Sediment
Erytrocyte
LPB
Leucocyte
LPB
Epitel
LPB
Casts
LPB
Cristal
LPB

Result
Yellow clear
Negative
Negative
Negative
1.000
7.0
Negative
Negative
Negative
Negative
Negative

Normal
Yellow
Negative
Negative
Negative
1.005 1.030
5-8
Negative

0-1
0-1
0-1
Negative
Negative

<3
<6

Negative
Negative

Negative

Fesces
Macroscopic
Color
Consistency
Blood
Mucus
Microscopic
Egg worm
Amoeba
Erytrocyte
Leucocyte

LPB
LPB
LPB

Result

Normal

Brown
Watery
Negative
Negative

Negative
Negative

Negative
Negative
0-1
0-1

Negative
Negative

Barium Meal: October 16th, 2015

Plain Abdominal X-ray : October 19th, 2015

Follow Up 16/10/2015
S

Lost appetite, bloody vomit (+) and bloody stool (+)

Sens : Alert, T : 37,9 C, BW : 4,9kg, BH : 64cm

Head: eye reflect +/+, isocor, pale conj. palpebra inferior+/+,
Ear/Nose/Mouth: normal
Neck: JVP R+2 cm H2O
Thorax : Symmetrical fusiform, retraction (-), HR : 125x/I, reguler,
murmur (-) RR : 30x/i, reguler, ronchi -/Abdomen : soepel, normal peristaltic, Hepar: palpeble 2cm BAC Lien:
palpeble SIII
Extremities : pulse 125bpm reguler, adequate pressure and volume, warm,
CRT <3, pretibial edema (-)

Marasmus
Gastrointestinal bleeding
Anemia

IVFD D5% NaCl 0,225% 20gtt/i (micro)

Folic acid 1x1 mg
Vitamin B Complex 1x1 tab
Vitamin C 1x1 tab
Diet F75 80 cc/3 hours + 1,6 cc mineral mix
Transfusion PRC 25 cc/24 jam
Inj Ceftriaxone 250 mg/12 hours/iv

Consult gastrohepatology division

Consult hematooncology division
Consult nutrition and metabolic disease division
Complete urine and fesces analysis
Check iron profile
Peripheral blood smear
Barium Meal

Follow Up 17/10/2015 19/10/2015

S

Lost appetite, bloody vomit (-), bloody stool (-), fever (+)

Sens : Alert, T : 37,7 C, BW : 4,9kg, BH : 64cm

Head: eye reflect +/+, isocor, pale conj. Palpebra inferior-/-, Ear/Nose/Mouth:
normal
Neck: JVP R+2 cm H2O
Thorax : Symmetrical fusiform, retraction (-), HR : 100x/I, reguler, murmur (-)
RR : 24x/i, reguler, ronchi -/Abdomen : soepel, normal peristaltic, Hepar: palpeble 2cm BAC Lien: palpeble
SIII
Extremities : pulse 100x/i, reguler, adequate pressure and volume, warm, CRT
<3, pretibial edema (-)
Resultfrom Gastrointestinal divison: recommend to do
Abdominal x-ray 2 position
Routine urine analysis, LFT

Marasmus
Gastrointestinal bleeding
Anemia

IVFD D5% NaCl 0,225% 20gtt/I (micro)

Folic acid 1x1mg
Vitamin B Complex 1x1 tab
Vitamin C 1x50mg
Diet F75 80cc/3 hours + 1,6cc mineral mix
Transfusion PRC 25cc/24jam
Inj ceftriaxone 250mg/12hours/iv

Scheduled for Abdominal X-ray

Expecting Barium Meal result

Follow Up 20/10/2015
S

Lost appetite, bloody stool (-), fever (-)

Sens : Alert, T : 37,5 C, BW : 4,9kg, BH : 64cm

Head: eye reflect +/+, isocor, pale conj. Palpebra inferior-/-,
Ear/Nose/Mouth: normal
Neck: JVP R+2 cm H2O
Thorax : Symmetris fusiformis, retraction (-), HR : 100x/I, reguler, murmur
(-) RR : 24x/i, reguler, ronchi -/Abdomen : soepel, normal peristaltic, Hepar: palpeble 2cm BAC Lien:
palpeble SIII
Extremities : pulse 100x/i, reguler, adequate pressure and volume, warm,
CRT <3, pretibial edema (-)

Marasmus
Gastrointestinal bleeding
Anemia

IVFD D5% NaCl 0,225% 20gtt/I (micro)

Inj. Ranitidine 5mg/12 hours/ IV
Folate acid 1x5mg
Vitamin B Complex 1x1 tab
Vitamin C 1x50mg
Diet F75 80cc/3 hours + 1,6cc mineral mix
Inj ceftriaxone 250mg/12hours/iv

Abdominal X-ray

Follow Up 21/10/2015
S

Bloody stool (-), fever (+)

Sens : Alert, T : 37,6 C, BW : 4,9kg, BH : 64cm

Head: eye reflect +/+, isocor, pale conj. Palpebra inferior +/+,
Ear/Nose/Mouth: normal
Neck: JVP R+2 cm H2O
Thorax : Symmetrical fusiform, retraction (-), HR : 92x/I, reguler, murmur
(-) RR : 24x/i, reguler, ronchi -/Abdomen : soepel, normal peristaltic, Hepar: palpeble 2cm BAC Lien:
palpeble SIII
Extremities : pulse 92x/i, reguler, adequate pressure and volume, warm,
CRT <3, pretibial edema (-)
Laboratorium result :
- Reticulocyte 3,17%
- Combs test (-)
- CRP 2,8
Procalcitonin 1,22

Result from Nutrition and metabolic disease division:

Food recall 24 hours:
Morning: porridge1/2 portion + carrot piece
Afternoon: porridge portion + potato piece
Night: porridge portion + carrot piece
Breast feeding on demand.
Therapy : - diet F75 80cc/3 hours + 1,6cc mineral mix
- Vit. A 100.000 unit (1x)
- Vit.B comp 1x1 tab
- Vit.c 1x50mg
- Cotrimoxazole 2x tspn

Marasmus
Gastrointestinal bleeding
Anemia
IVFD D5% NaCl 0,225% 20gtt/I (micro)
Inj. Ranitidine 5mg/12 hours/ IV
Folic acid 1x1mg
Vitamin B Complex 1x1 tab
Vitamin C 1x50mg
Diet F75 80cc/3 hours + 1,6cc mineral mix
Cotrimoxazole syr 2xcth1/2

Follow Up 22/10/2015- 26/10/2015

S

Lost appetite, bloody stool (-), fever (-)

Sens : Alert, T : 37 C, BW : 5kg, BH : 64cm

Head: eye reflect +/+, isocor, pale conj. Palpebra inferior +/+,
Ear/Nose/Mouth: normal
Neck: JVP R+2 cm H2O
Thorax : Symmetris fusiformis, retraction (-), HR : 98x/I, reguler, murmur
(-) RR : 24x/i, reguler, ronchi -/Abdomen : soepel, normal peristaltic, Hepar: palpeble 2cm BAC Lien:
palpeble SIII
Extremities : pulse 98x/i, reguler, adequate pressure and volume, warm,
CRT <3, pretibial edema (-)

Marasmus
Gastrointestinal bleeding
Post Hemorrhagic Anemia

IVFD D5% NaCl 0,225% 20gtt/I (micro)

Inj. Ranitidine 5mg/12 hours/ IV
Folic acid 1x1mg
Vitamin B Complex 1x1 tab
Vitamin C 1x50mg
Diet F100 80cc/3 hours + 1,6cc mineral mix
Cotrimoxazole syr 2xcth1/2

October 26th, 2015 patient PBJ

Discussion
Nutritional status
(BW/BH)
- WHO 2006: <5years
- CDC 2000: >5years
Clinical Manifestation
Old man face, irritable, muscle
hypotrophy, subcutaneous fat
loss, piano-sign, baggy-pants

Deficiency calories
and energy, occur
mainly at the time
of weaning (<5yo)

MARASMUS

Decreased energy intake

Loss of ingested calories (emesis,
diarrhea, burns)
Increased energy expenditure
Combination (chronic disease)

Negative energy balance

Descreased
in physical
activity

lethargy

Decreased
basal energy
metabolism

Slowing of
growth

Weight loss

Case: loss apetite and body weight is difficult to increase since 2 months ago

 Body fluid compartment

High total body water, significant reduction in adipose and lean
mass, muscle cell atrophy
arm circumference
Metabolic adaptation
similar to starvation, reduced energy metabolism
risk of
hypothermia
Digestive tract
villous atrophy of jejunal mucosa, decreased HCl excretion,
slowing peristalsis bacterial overgrowth
Endocrine system
free plasma level of cortisol in hypoalbuminemia
Cardiovascular
smaller and thinner cardiac muscle, lower stroke volume,
bradicardia and hypotension

Treatment of severe malnutrition

Intial refeeding
F75 (75 kcal and 0,9 gr protein/ 100ml)
frequent (every 23 h) oral small feeds of low osmolality
and low lactose
nasogastric feeding if the child is eating 80% of the
amount offered at two consecutive feeds
calories at 100 kcal/kg per day
protein at 11.5 g/kg per day
liquid at 130 ml/kg per day or 100 ml/kg per day (oedema)
encourage continued breastfeeding
Gradual transition from starter F-75 to F-100 (100 kcal and
2.9 gr protein/100ml)

Case:
Day 1 day 7 (the stabilization and transition
phase )
80cc F-75 every 3 hours and 1,6cc mineral
mix
Day 8 (start rehabilitation phase)
catch-up feeding F-100 80cc every 3 hours and
1,6cc mineral mix

Monitoring
Poor (< 5 g/kg per day), re-assessment
Moderate (510 g/kg per day), check intake
targets are being met or infection
Good (> 10 g/kg per day)
Case:
Poor: the weight gain 1gr on rehabilitation phase

Summary
AK, 9 months old boy was admitted on October, 15th 2015 with
complaint of losing appetite, weight loss, having black stool.
Patient was diagnosed with Marasmus + Gastrointestinal
bleeding + Anemia post hemorrhagic. Patient was given IVFD
D5% NaCl 0,225% 20gtt/i (micro), PRC 25 cc/ 24 (4 bags), inj.
ranitidine 5mg/12 hours/ iv, folic acid 1x5 mg once then
continued with1x1mg, vitamin A 1x100.000 IU once, vitamin
B complex 1x1 tab, vitamin C 1x50mg, diet F-75 80 cc/ 3 hours
+ 1,6 cc mineral mix then continued diet F100 80cc/3 hours +
1,6cc mineral mix, inj. ceftriaxone 250 mg/ 12 hours/iv,
cotrimoxazole syr 2xcth1/2

Thank You