Concomitant Kwashiorkor and Zinc Deficiency in a Middle-Aged Obese Woman; Characteristics and Risk

Concomitant Kwashiorkor and Zinc Deficiency in a Middle-Aged Obese Woman; Characteristics and Risk Factors of Adults Who Develop Kwashiorkor in Developed Countries: a case report and review of literat

Maureen Ezekor

University of Texas Medical Branch

Kwashiorkor is a protein-calorie malnutrition commonly seen in children from impoverished countries, but kwashiorkor has also been described in industrialized countries with an increasing incidence. Despite having a higher prevalence in pediatric populations, kwashiorkor can occur in adults and diagnosis may be delayed due to low clinical suspicion. We report a case of an obese middle-aged woman with concurrent zinc and protein deficiency likely caused by poor socioeconomic status, comorbid illnesses, and an underlying psychiatric disorder. Additionally, we present a review of literature of the characteristics and risk factors of adults who develop kwashiorkor in affluent countries.

We present a 58-year-old female with a two-month history of a diffuse, painful rash spreading over her body. The rash was unresponsive to antibiotics, oral fluconazole, nystatin, and miconazole cream. She had a past medical history of morbid obesity, hypertension, hyperlipidemia, type II diabetes, polyneuropathy, depression, and recent hospitalization for abscesses. Patient experienced unstable living conditions and was homeless at various times in her life. Physical exam revealed erythematous, desquamating, psoriasiform plaques with superficial scaling and scattered erosions covering her arms, legs, abdomen, back, and intertriginous folds. Our patient’s clinical and laboratory findings were consistent with kwashiorkor and concomitant zinc and vitamin B12 deficiency. Multiple factors likely contributed to this patient’s development of multiple nutritional deficiencies including the patient’s poor socioeconomic status, comorbid medical conditions, and a history of depression.

Although frequently described as a disease of children in poverty-stricken countries, kwashiorkor may present in adults in resource-rich countries. History of bariatric surgery, HIV positive status, anorexia nervosa, chronic disease, food faddism, and poor socioeconomic status are all risk factors for the development of kwashiorkor. Dermatologists should aim to counsel patients on nutritional care and be aware of these risk factors and the dermatologic findings of kwashiorkor. In addition, nutritional deficiencies often coexist and clinical findings from multiple deficiencies may overlap as demonstrated with our patient. Kwashiorkor is a potentially life-threatening disease and early identification and treatment with protein supplementation may reduce complications and improve clinical outcome.