Q. A 4 years old girl presented with recurrent watery diarrhea for the past 6 months and generalized swelling over the body for the past 15 days. There is no fever, vomiting or contact with TB patient. There are no other illnesses in the past. She was born at full term by normal delivery and had a birth weight of 2.75kg. She was on exclusive breast feeds till 5 months of age following which weaning diet was started and currently she was only on dal and rice with calorie intake of 400kcal, day and proteins of 7gm, day. She had history of pica. She was the first child of her parents and mother was 19 years old and educated upto 5th standard. She was immunized till date.
On examination, her weight was 8.5kgs { Less than 3rd centile} and height was 76cms { Less than 3rd centile}. She had anasarca and dry skin. Her hair was depigmented and easily pluckable. Heart rate was 130, min, respiratory rate was 30, min and blood pressure was 100, 80mm of Hg. She had generalized lymphadenopathy, pallor, angular cheilitis and beading of the ribs was present. Tongue was bald. She had conjunctival xerosis. On systemic examination, she was apathetic and had hepatomegaly. Other systems were normal.
On investigation, her hemoglobin was 4.6gm, dl with hypochromic microcytic anemia, white cell count was 7500, cumm {60 percent polymorphs, 40 percent lymphocytes} and platelet count was 5,40,000, cumm. ESR was 15mm at end of 1 hour. Her blood sugar, serum electrolytes and renal and liver function tests were normal. Her stool examination showed ova of hookworm, Trichuris trichura, ascariasis and cysts of e.histolytica. Chest X-ray shows cardiomegaly with osteopenia. Serum calcium is 8.2mg, dl {Normal = 8.5-11mg, dl}, normal phosphorus and high alkaline phosphatase.