Differentials
Marasmus
SIGNS / SYMPTOMS
Malnutrition without oedema, but a weight for height/length z-score <-3 or mid-upper arm circumference (MUAC) <11.5 cm.
INVESTIGATIONS
Clinical diagnosis.
Chronic undernutrition
SIGNS / SYMPTOMS
Malnutrition without oedema and a weight or length for age z-score <-2.
INVESTIGATIONS
Clinical diagnosis.
Congestive heart failure
SIGNS / SYMPTOMS
History of congenital heart disease, heart murmur, cyanosis, clubbing; child may have hepatomegaly and hypoxaemia.
INVESTIGATIONS
Echocardiography indicates primary anatomical heart lesion.
Glomerulonephritis
SIGNS / SYMPTOMS
Child may have haematuria, renal failure, and decreased urine output with or without hypertension.
INVESTIGATIONS
Proteinuria on urinalysis.
Elevated urea or creatinine in serum.
Nephrotic syndrome
SIGNS / SYMPTOMS
Nephrotic syndrome associated with marked ascites, or pleural effusions; no skin dermatosis present. Oedema often more pronounced in face rather than lower extremities.
INVESTIGATIONS
Proteinuria on urinalysis.
Elevated urea or creatinine.
Hepatic cirrhosis
SIGNS / SYMPTOMS
Chronic condition; jaundice, splenomegaly, and ascites are common; multiple angiomata of the skin often seen in cirrhosis. Child may have oesophageal varices.
INVESTIGATIONS
Liver function tests: elevated bilirubin, serum transaminases, reduced serum albumin, and prolonged coagulation.
Haemolytic anaemia
SIGNS / SYMPTOMS
Pallor of mucous membranes and conjunctiva. Child may have signs of cardiac failure.
INVESTIGATIONS
MCHC; may show reticulocytes or spherocytes.
Reticulocyte count; indicates appropriate marrow response to anaemia. Rise should be 4% to 5%, but may be much higher.
Unconjugated bilirubin; elevated but not more than 5 g/dL unless child also has liver failure.
Allergic reaction
SIGNS / SYMPTOMS
Oedema is usually asymmetrical and not dependent. Pruritus localised to the site of oedema; usually presents peri-orbitally.
INVESTIGATIONS
Trial of treatment: improves with administration of an antihistamine or norepinephrine (noradrenaline) if severe reaction occurs with marked facial oedema and swelling.
Protein-losing enteropathy
SIGNS / SYMPTOMS
Clinical presentation of PLE varies widely, reflecting its diverse aetiologies.
Presence of PLE does not preclude a diagnosis of concomitant kwashiorkor.
INVESTIGATIONS
Faecal alpha-1 antitrypsin should be tested for in high resource settings.
Lymphoedema
SIGNS / SYMPTOMS
Usually brawny non-pitting oedema, with adenopathy.
INVESTIGATIONS
Lymphoscintigraphy; increased tracer uptake into soft tissue and lymphatic webs, localised to affected area.
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