Case Report

MARASMUS
Compiled by

Apriany Cordias A. Silalahi

Johanna Sihombing
Supervised by

110100232

110100224

dr. Oke Rina Ramayani, Sp. A (K)

INTRODUCTION
Marasmus is the most common form of acute
malnutrition in nutritional emergencies and, in
its severe form, can very quickly lead to death if
untreated.
Malnutrition is directly responsible for 300,000
deaths per year in children younger than 5 years.
Basic Health Research 2013 there is an
increased prevalence of malnutrition-less, namely
19.6%, of which 5.7% severe malnutrition and
13.9% less nutritional status.
Marasmus is one of the 3 forms of serious
protein-energy malnutrition (PEM).

LITERATURE REVIEW
Malnutrition is the result of deficiency of protein,
energy, minerals as well as vitamins leading to
loss of body fats and muscle tissues.
Aetiology & Risk Factor

Direct
Foods
Presence or absence of
infectious disease

Indirect
Nutrient content
Purchasing power
Belief of food & health
of the mother
Presence or absence
healthcare

PATHOPHYSIOLOGY
Lack of food
body is trying to preserve life
The bodys ability to store carbo very litte
Protein catabolism
During fasting fat tissue are broken down.
The body will defend itself not to break down proteins
again after losing roughly half of the body

CLINICAL SIGN
Poor growth
Wasting
Alertness
Appetite
Anorexia
Diarrhoea
Anemia
Skin sores
Hair changes
Dehydration

DIAGNOSIS

Clinical Presentation

Anthropometry
(BW/BL)

Severe malnutrition Looked very thin

< -3 SD **)

Mild-moderate

Looked thin

- 3 SD < - 2 SD

Health

Looked health

- 2 SD 2 SD

Obesity

Looked fat

> 2 SD

malnutrition

CONDITION OF MALNUTRITION
1st condition

Found:

Shock

Lethargy

2nd condition

Vomiting and/or diarrhoea or dehydration

Found:

3rd condition

Vomiting and/or diarrhoea or dehydration

Found:

Lethargy

Vomiting and/or diarrhoea or dehydration

4th condition

Found:

Lethargy

5th condition

Not found:

Shock

Lethargy

Physical Examination, BW/BL, AC

Severe malnutrition

Severe malnutrition

with complications

without complications malnutrition

Children with one or

Children with one or

AC>11.5cm<12.5cm

more signs:

more signs:

(children 6-59 months)

-Looked very thin

-Looked very thin

(BW/BL<-2 to -3 SD)

- BW/BL<-3SD

-BW/BL<-3SD

And

-AC<11,5cm (children 6-

-AC<11,5cm (children 6-

Goodly feeding

59 months) and one or

59 months)

No clinical abnormality

more medical

And

complications signs:

-goodly feeding

-Anorexia

-without any medical

-Severe pneumonia

complications

-Severe anemia

Mild-moderate

ANOTHER LABORATORY
EXAMINATION
Blood glucose
Peripheral blood smear
Urinalysis
Stool examination
Electrolyte
Ferritin
Mantoux test
Chest X-ray
ECG

MANAGEMENT

Some important things we must attend

are:
Don't give Fe before 2nd week (Fe is given in
rehabilitation and further management phase).
Don't give intravenous fluid drip unless the patient is
in shock or severe dehydration.
Don't give high protein diet in stabilization phase.
Don't give diuretics to patients with kwashiorkor.

PROGNOSIS
Getting

treatment early generally leads to

good results.
However, the child may be left with
permanent physical and mental problems.
If treatment is not given or comes too late,
this condition is life-threatening.

CASE REPORT

HISTORY OF DISEASE
KAP, a 2 years 5 months old girl, 7 kg of BW and 79
cm of BH.
Her chief complaint is difficulty of breathing
happened for 2 days, and is not related with weather
and activity.
Cough (+), been experienced for 2 weeks. At first it
was dry, but then became productive. History of
recur cough since this past 2 months.
Her grandmother also had productive cough for a
month. History of fever was 2 months ago, lasted for
this 2 weeks. The temperature was up and down.
Diarrhea was experienced for a day, without losing
weight. Vomiting was denied. No history of family
having the same condition.

HISTORY OF PREGNANCY
Patients mother was 27 years old during
pregnancy; aterm
history of fever during pregnant (-) History of cough
(-) History of flu (-) History of taking drugs or
traditional drinks (-) History of trauma (-) History of
hypertension (-) History of DM (-)

HISTORY OF BIRTH, FEEDING,

AND IMMUNIZATION
Birth was assisted by a GP
born spontaneously and cried spontaneously;
bluish (-)
BW was 2700 gram, BL was 46 cm, head
circumference was not measured
6 months of exclusive breast feeding, additional food
since 7 months old and family food was given from 19th
week onward.
Immunization: BCG, Polio 4 times, Hepatitis B 3
times, DPT 3 times, and Measles.

PHYSICAL EXAMINATION
Sens: CM, T: 38.0C, HR: 100 bpm, RR: 48 x/i,
anemic (-), icteric (-), dyspnea (+), cyanosis
(-), edema (-).
Generalized Status
BW: 7 kg, BL: 79 cm,
BW/age: Z-score <-3 (severely wasted)
BL/age: Z-score < -3 (severely stunted)
BW/BL: Z-score<-3 (severely wasted)

LOCALIZED EXAMINATION
Head
:Face: edema (-)
Eyes:superior and inferior
palpebra edema(-), light
reflex +/+, isochoric pupil,
no pale in inferior palpebral
conjunctiva, no icteric in
sclera, Old man face (+),
thin hair (+)
Ears, nose, mouth: within
normal range

Extremities : pulse 100 bpm

regular,adequate p/v, felt
warm, CRT < 3 edema
pretibial (-), pale (-)
Thinning subcutaneous fat
(+), hyperthropy muscle (-),
baggy pants (-)

Neck
:Lymph node
enlargement (-)
Thorax : Symmetrical
fusiform, retraction (+)
HR: 100 bpm, regular,
murmur (-); RR: 48x/i,
regular, ronchi (+/+),
intercosta clearly visible (-),
vertebra protude (-)

Abdomen: normal, symmetric,

normal peristaltic, liver and
spleen: unpalpable

Anogenital : Female

Diagnosis bronchopneumonia

Differential diagnosis lung TB

Test

Result

Unit

References

Hemoglobin

10.40

g%

11.3-14.1

Erythrocyte

3.77

106/mm3

4.40-4.48

Leucocyte

18.13

103/mm3

6.0-17.5

Thrombocyte

732

103/mm3

217-497

Hematocrite

32.30

37-41

Eosinophil

1.0

1-6

Basophil

0.900

0-1

Neutrophil

62.90

37-80

Lymphocyte

27.50

20-40

Monocyte

7.70

2-8

Neutrophil absolute

11.41

103/L

1.9-5.4

Lymphocyte absolute

4.99

103/L

3.7-10.7

Monocyte absolute

1.39

103/L

0.3-0.8

Eosinophil absolute

0.18

103/L

0.20-0.50

Basophil absolute

0.16

103/L

0-0.1

MCV

85.70

fL

81-95

MCH

27.60

Pg

25-29

MCHC

32.20

g%

29-31

LABORATORY FINDINGS
Test

Result

Unit

References

Carbohydrate Metabolism
Blood Glucose

151.0

mg/dL

< 200

Electrolyte
Natrium

138

mEq/L

135-155

Potassium

4.3

mEq/L

3.6-5.5

Chloride

104

mEq/L

96106

Blood Gas Analysis

pH

7.320

7.35-7.45

pCO2

21.0

mmHg

38-42

pO2

183.0

mmHg

85-100

HCO3

10.8

mmol/L

22-26

Total CO2

11.4

mmol/L

19-25

Kelebihan basa

6.3-14.0

mmol/L

(-2)-(+2)

100.0

95-100

(BE)
Sa O2

RADIOLOGIC FINDING

Therapy:
O 1L/m
2

Inj. Meropenem 140 mg/8 jam

Salbutamol 3x0,5 mg
Ambroxol 3x5 mg
As folat 1x1 mg
Vit C 1x100 mg
Vit B complex 1x1

Planning Assesment:
Complete Blood count

Chest X-Ray
Chest USG
Chest CT-Scan
Stools analysis

FOLLOW-UP

3rd - 6th September 2015

Difficulty of breathing (+), cough (+), diarrhea (+)

Sensorium: Compos Mentis, Temp: 38.0 oC.

Head :Face: old man face(+)

A
P

Body weight: 7 kg, Body length: 79

Thorax : symmetrical fusiform, retraction
cm,(+)
arm circumference 10 cm
- HR: 100 bpm, regular, murmur (-) BW/age: Z-score < -3 (severely
wasted)
- RR : 48x/i, regular, ronchi (+/+)
BL/age: -3 < Z-score < -2 (severely
Extremities : Thinning subcutaneous fat
stunted)
BW/BL: Z-score < -3 (severely
DD/ Bronchopneumonia + Marasmus wasted
- O2 1L/m
Tuberculosis
Arm circumference : Z-score < -3
- Inj. Meropenem 140 mg/8 hours
-

Salbutamol 3x0,5 mg

Ambroxol 3x5 mg

As folat 1x1 mg

Vit C 1x100 mg

Vit B complex 1x1

Vit A 1 x 100.000 IU

7th September 2015

S

Difficulty of breathing (+), cough (+), diarrhea (+)

O Sensorium: Compos Mentis, Temp: 38.0 oC.

Head :Face: old man face(+)
Thorax : symmetrical fusiform, retraction (+)

Body weight: 7,8 kg, Body length:

79 cm, arm circumference 10 cm
- RR : 30 x/i, regular, ronchi (+/+)
BW/age: Z-score < -3 (severely
Extremities : Thinning subcutaneous fat wasted)
BL/age: -3 < Z-score < -2 (severely
A DD/ Bronchopneumonia + Marasmus
stunted)
BW/BL: Z-score < -3 (severely
Tuberculosis
wasted
P - O2 1L/m
Arm circumference : Z-score < -3
-

HR: 110 bpm, regular, murmur (-)

Inj. Meropenem 140 mg/8 jam

Salbutamol 3x0,5 mg

Ambroxol 3x5 mg

As folat 1x1 mg

Vit C 1x100 mg

Vit B complex 1x1

Diet F100 110 cc/3 hours + Mineral mix 2,2 cc

8th until 9th September 2015

S

Difficulty of breathing (+), cough (+), diarrhea (+)

Sensorium: Compos Mentis, Temp: 38.0 oC.

Head :Face: old man face(+)
Thorax : symmetrical fusiform, retraction
(+)weight: 7,9 kg, Body length:
Body
79 cm, arm circumference 10 cm
- HR: 88 bpm, regular, murmur (-)

BW/age: Z-score < -3 (severely

wasted)
Extremities : Thinning subcutaneous fat
(+)
BL/age:
-3 < Z-score < -2 (severely
stunted)
DD/ Bronchopneumonia + Marasmus BW/BL: Z-score < -3 (severely
wasted
Tuberculosis
Arm circumference : Z-score < -3
-

RR : 28 x/i, regular, ronchi (+/+)

O2 1L/m

Inj. Meropenem 140 mg/8 jam

Salbutamol 3x0,5 mg

Ambroxol 3x5 mg

As folat 1x1 mg

Vit C 1x100 mg

Vit B complex 1x1

Diet F100 110 cc/3 hours + Mineral mix 2,2 cc

10th September 2015

OUT PATIENT

SUMMARY

KAP, a 2 years 5 months old girl, with 7 kg of BW and 79 of BH,

came to RSUP Haji Adam Malik Medan on 2nd September at 3
pm. She is diagnosed with bronchopneumonia with marasmus.
The diagnosis was estabilished based on history taking, clinical
manifestations, physical diagnostics, and laboratory findings.