HYDERABAD — A 5-month-old boy in Hyderabad, India, was diagnosed with kwashiorkor after his mother began feeding him diluted formula, according to a case report in the New England Journal of Medicine. The child, who had been exclusively breastfed until 20 days prior, presented to an outpatient clinic with a rash that had developed three weeks earlier.

The boy's mother switched to diluted formula due to difficulties producing enough milk. Upon examination, the boy was irritable and exhibited sparse, wispy, hypopigmented hair. His rash resembled flaking paint, with the outermost layer of skin on his legs, arms, and torso peeling and showing hyperpigmented patches. The skin layer beneath these patches was unusually hypopigmented. Pitting edema was also observed on his arms and legs.

The boy's weight-for-age z score was recorded as -3.4, and his length-for-age z score was -5.6. According to the World Health Organization, normal z-score ranges are between -2 and 2. Jashir Ahammed Kolathil and Gadhiraju Manisha Varma, both affiliated with the All India Institute of Medical Sciences-Bibinagar in Hyderabad, reported the case.

He was admitted to the hospital, where he received a therapeutic milk formula. By the seventh day of his admission, the boy became more active, and his skin lesions had diminished. During a follow-up visit two weeks after his discharge, his rash had abated, and his weight had returned to a normal level.

Kwashiorkor, also known as edematous malnutrition, is a severe form of protein deficiency characterized by pitting edema. This condition is prevalent in equatorial and sub-Saharan Africa. Precise estimates of cases are difficult, as kwashiorkor is not included in routine epidemiological surveys, but hundreds of thousands of cases are believed to occur annually. If left untreated in poverty-stricken settings, kwashiorkor has a fatality rate ranging from 30% to 50%.

Malnourished patients can be diagnosed with kwashiorkor based on edema alone. The term was officially introduced as "kwashiorkor" in 1935 by Cicely Williams, who encountered the illness in children in Ghana. The term originates from the Ga language, where "kwashi" means first and "orkor" means second. Historically, mothers would observe their first child fall ill after a second child was born and the older child was weaned. Standard treatment for kwashiorkor involves special powders like formula 75 and formula 100, and children may receive ready-to-use therapeutic food during recovery, though relapse rates can be high. While this case occurred in India, cases of kwashiorkor have also been reported in the U.S., sometimes linked to underlying diseases, difficulties absorbing protein, or maltreatment and neglect.