Patient selection: severe malnutrition in a developing country
Conditions that may explain clinical deterioration:
(1) refeeding syndrome
(2) celiac crisis
(3) infection (bacterial, viral, parasitic)
In the refeeding syndrome the patient shows anemia, hypoalbuminemia and electrolyte deficiencies (hypophosphatemia, hypokalemia, hypocalcemia). Management involves slow and gradual feeding with correction of electrolytes.
Celiac crisis occurs in a patient with celiac disease following exposure to a gluten source. The patient may show many of the same findings as in the refeeding syndrome. A true gluten-free diet makes this diagnosis less likely. Management may include systemic corticosteroids.
Infections in a developing country may include enteric bacteria, acute viral infections and parasitic disease. Food and water supplies in a developing country may be suboptimal. HIV testing should be performed if indicated. Management involves identifying the infectious cause and treating it appropriately.
In addition, deficiencies in nutritional replacement may allow for vitamin and trace metal deficiencies to go uncorrected which may limit response to nutritional replacement.
