Differentials
Marasmus
SIGNS / SYMPTOMS
Malnutrition without edema, 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 edema 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 hypoxemia.
INVESTIGATIONS
Echocardiography indicates primary anatomic heart lesion.
Glomerulonephritis
SIGNS / SYMPTOMS
Child may have hematuria, renal failure, and decreased urine output with or without hypertension.
INVESTIGATIONS
Proteinuria on urinalysis.
Elevated BUN or creatinine in serum.
Nephrotic syndrome
SIGNS / SYMPTOMS
Nephrotic syndrome associated with marked ascites, or pleural effusions; no skin dermatosis present. Edema often more pronounced in face rather than lower extremities.
INVESTIGATIONS
Proteinuria on urinalysis.
Elevated BUN 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 esophageal varices.
INVESTIGATIONS
Liver function tests: elevated bilirubin, serum transaminases, reduced serum albumin, and prolonged coagulation.
Hemolytic anemia
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 anemia. 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
Edema is usually asymmetrical and not dependent. Pruritus localized to the site of edema; usually presents periorbitally.
INVESTIGATIONS
Trial of treatment: improves with administration of an antihistamine or norepinephrine if severe reaction occurs with marked facial edema and swelling.
Protein-losing enteropathy (PLE)
SIGNS / SYMPTOMS
Clinical presentation of PLE varies widely, reflecting its diverse etiologies.
Presence of PLE does not preclude a diagnosis of concomitant kwashiorkor.
INVESTIGATIONS
Fecal alpha-1 antitrypsin should be tested for in high resource settings.
Lymphedema
SIGNS / SYMPTOMS
Usually brawny nonpitting edema, with adenopathy.
INVESTIGATIONS
Lymphoscintigraphy; increased tracer uptake into soft tissue and lymphatic webs, localized to affected area.
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