A 19-year-old woman with anorexia nervosa undergoes surgery for acute appendicitis. The postoperative course is complicated by acute respiratory distress syndrome, and she remains intubated for 10 days. She develops wound dehiscence on postoperative day 10. Laboratory data show a white blood cell count of 4000/ µL, hematocrit 35%, albumin 2.1 g/dL, total protein 5.8 g/dL, transferrin 54 mg/dL, and iron-binding capacity 88 mg/dL. You are considering initiating nutritional therapy on hospital day 11. Which of the following is true regarding the etiology and treatment of malnutrition in this patient?
A. She has marasmus, and nutritional support should be started slowly.
B. She has kwashiorkor, and nutritional support should be aggressive.
C. She has marasmic kwashiorkor, kwashiorkor predominant, and nutritional support should be aggressive.
D. She has marasmic kwashiorkor, marasmus predominant, and nutritional support should be slow.
The answer is C. The two major types of protein energy malnutrition are marasmus and kwashiorkor; differentiating the two is extremely important in the malnourished patient since this directly effects your therapy. This patient has marasmic kwashiorkor due to the impact of her anorexia nervosa, the acute stressor of the surgery, and the 10 days of starvation. This patient has chronic starvation (marasmus) as well as the major sine qua non of kwashiorkor; i.e., reduction of levels of serum proteins. She is kwashiorkor predominant because of the acute starvation and the severely low levels of serum proteins. Vigorous nutritional therapy is indicated for kwashiorkor.