P2.L225: Eczema, Eczema, Eczema… Kwashiorkor?

Introduction: Kwashiorkor is a severe protein malnutrition due to inadequate protein intake despite sufficient caloric intake. It is notable for a protuberant abdomen, bilateral lower extremity pitting edema, failure to thrive, lethargy, and a distinctive rash known as “flaky paint” dermatosis. We present a case of a 9-month-old male admitted with a worsening rash indicative of underlying severe protein malnutrition known as Kwashiorkor.

Case Description: A 9-month-old African-American male presented to the emergency room with a 3-month history of worsening full-body rash and bilateral lower extremity swelling. During multiple prior emergency room visits, he was diagnosed with severe eczema and treated with topical steroids with no improvement. He was later admitted for severe eczema flare and lower extremity cellulitis. Physical examination revealed lower extremity pitting edema and dry, patchy, peeling hyperpigmented skin revealing hypopigmented and erythematous skin underneath covering the body. Growth charts were notable for height and weight percentiles < 1%. Dermatology was consulted and identified the rash as “flaky paint” dermatosis leading to the diagnosis of Kwashior. Further investigation revealed parental adoption of a vegan diet for both mother and infant around 6 months of age, which mainly consisted of fruits and limited formula intake. Laboratory findings confirmed hypoalbuminemia and iron, vitamin D, zinc, and magnesium deficiencies. With a multidisciplinary team of gastroenterology, nutrition, and social work, the patient’s skin, edema, and weight showed marked improvement after a 3-week hospitalization, which included the gradual reintroduction of formula, vitamin supplementation, close monitoring for refeeding syndrome, and parental health literacy education.

Discussion: Kwashiorkor typically occurs in developing nations and regions affected by famine, where access to protein-rich foods is limited. However, with the increasing prevalence of restrictive diets in developed countries, cases of Kwashiorkor among infants and young children are rising. We present a case of a 9-month-old infant diagnosed with Kwashiorkor in the United States with the characteristic skin finding of “flaky paint” dermatosis with symmetric peripheral pitting edema. The skin finding is easily mistaken for eczema, which delays diagnosis and treatment. Heightened awareness identifying the physical exam findings of Kwashiorkor can lead to early recognition and intervention.

Conclusion: Pediatricians play a vital role in identifying and addressing nutritional deficiencies in infants, especially during the early stages of food introduction, transition, and changes. The case highlights the need for improved parental education on proper infant nutrition during dietary changes to prevent malnutrition and increased healthcare providers' awareness of the dermatologic manifestations of severe protein malnutrition to avoid a delay in care.