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LETTER TO EDITOR
Year : 2018  |  Volume : 19  |  Issue : 3  |  Page : 285-286

Severe acute malnutrition with hyperpigmentation: An uncommon association


1 Department of Paediatrics, Aminu Kano Teaching Hospital/Bayero University, Kano, Nigeria
2 Nursing Department, Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Web Publication28-Jun-2018

Correspondence Address:
Dr. Ibrahim Aliyu
Department of Paediatrics, Aminu Kano Teaching Hospital/Bayero University, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_25_17

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How to cite this article:
Aliyu I, Ibrahim ZF. Severe acute malnutrition with hyperpigmentation: An uncommon association. Indian J Paediatr Dermatol 2018;19:285-6

How to cite this URL:
Aliyu I, Ibrahim ZF. Severe acute malnutrition with hyperpigmentation: An uncommon association. Indian J Paediatr Dermatol [serial online] 2018 [cited 2019 Dec 10];19:285-6. Available from: http://www.ijpd.in/text.asp?2018/19/3/285/216944



Sir,

Malnutrition is a big problem in most under developing countries; it may present as acute or chronic undernutrition. Severe acute malnutrition may manifest as kwashiorkor, marasmus, or marasmic kwashiorkor.

Kwashiorkor is a disease associated with weaning especially toward the end of infancy, due to deficiencies in calories and predominantly protein. This result in cellular energy imbalance presenting with peripheral edma, and a fall in the weight for height measurement;[1] they are also prone to micronutrient deficiencies resulting in other common manifestations such as electrolyte derangements, hypoglycemia, anemia, skin excoriation, and depigmentation. On the other hand, marasmus is mostly associated with calorie deficiency; the skin pigmentary changes associated with kwashiorkor are uncommon with marasmus. Therefore, the association of generalized hyperpigmentation in childhood marasmus is a rare occurrence; hence, the case of a 2-year-old boy who presented with weight loss, diarrhea, fever, and a poor nutritional history; that developed generalized hyperpigmentation involving the trunk, extremities, face, both palms and soles is reported. He was essentially normal at birth with normal skin coloration; his problem started 3 months before presentation following abrupt weaning, this was followed with recurrent bouts of diarrhea, fever, and poor food intake. He weighed 7 kilogrammes which was <−3 Z-score for age; the mid-upper arm circumference was 11 cm (undernourished), occipitofrontal circumference was 47 cm. The respiratory, cardiovascular, and hematological systems evaluations were not remarkable.

Hyperpigmentation has been reported in malnutrition, especially in children with kwashiorkor, they occur in patchy distribution with flaking of the skin often described as “flaky paint dermatosis.”[2] The exact mechanism of hyperpigmentation in malnutrition is not completely understood, but micronutrient deficiencies may be implicated. Deficiency of niacin, pyridoxine (Vitamin B6), zinc[3] and Vitamin B12.[4] Vitamin 6 deficiency results in pellagra which is characterized by hyperpigmentation often limited to sun-exposed areas such as the neck, and limbs[5] while zinc deficiency may be associated with extensive dermatosis on the extremities and peri-oral region (acrodermatitis enteropathica);[6] however, in the index case, the hyperpigmentation was generalized [Figure 1]. The exact cause in the index is not clear. Hyperpigmentation has been associated with secondary malnutrition; Sander et al.[7] reported a case of kwashiorkor with coeliac disease and Hartnup's disease who improved on nutritional rehabilitation. The index case had nutritional rehabilitation with remarkable improvement, but the pigmentation persisted. However, limited resources and nonavailability of essential facilities made assay for specific micronutrients difficult in this case.
Figure 1: Extensive hyperpigmentation; with hypopigmentation of the posterior neck area

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  References Top

1.
de Onís M, Monteiro C, Akré J, Glugston G. The worldwide magnitude of protein-energy malnutrition: An overview from the WHO Global Database on Child Growth. Bull World Health Organ 1993;71:703-12.  Back to cited text no. 1
    
2.
Latham MC. The dermatosis of kwashiorkor in young children. Semin Dermatol 1991;10:270-2.  Back to cited text no. 2
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3.
Eastlack JP, Grande KK, Levy ML, Nigro JF. Dermatosis in a child with kwashiorkor secondary to food aversion. Pediatr Dermatol 1999;16:95-102.  Back to cited text no. 3
[PUBMED]    
4.
Rasmussen SA, Fernhoff PM, Scanlon KS. Vitamin B12 deficiency in children and adolescents. J Pediatr 2001;138:10-7.  Back to cited text no. 4
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5.
Seear M, Lockitch G, Jacobson B, Quigley G, MacNab A. Thiamine, ribofl avin, and pyridoxine defi ciencies in a population of critically ill children. J Pediatr 1992;121:533-8.  Back to cited text no. 5
[PUBMED]    
6.
Kuramoto Y, Igarashi Y, Tagami H. Acquired zinc deficiency in breast-fed infants. Semin Dermatol 1991;10:309-12.  Back to cited text no. 6
[PUBMED]    
7.
Sander CS, Hertecant J, Abdulrazzaq YM, Berger TG. Severe exfoliative erythema of malnutrition in a child with coexisting coeliac and Hartnup's disease. Clin Exp Dermatol 2009;34:178-82.  Back to cited text no. 7
[PUBMED]    


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