CHAPTER 1

INTRODUCTION

Approximately 826 million people in the world are undernourished792

million people in the developing world and 34 million in the developed world.
John Mason and colleagues claimed that 32% of the global disease burden could
be removed by eliminating malnutrition, whereas others have concluded that even
this figure is a gross understatement especially with the emergence of HIV/AIDS.
Undernutrition is not necessarily caused by a lack of food, and it is not unique to
poor populations. Even in rich nations, there are malnourished people. Infection
and malnutrition have always been intricately linked. Five infectious diseases
account for more than one-half of all deaths in children aged <5 years, most of
whom are undernourished 1. Micronutrient deficiencies have effects such as poor
growth, impaired intellect, and increased mortality and susceptibility to infection.
The worldwide magnitude of parasite infection is enormous. It is understood that
parasites may lead to malnutrition, but the extent to which malnutrition causes
increased parasite infestation is not known; thus, the conditions need to be
addressed together. Nutritional deficiencies associated with pregnancy are
associated with poor immune response to infection. Because this immune
deficiency is partially compensated by breast-feeding, this is the single best way
to protect infants from infection 2.

Deficiency in macronutrients such as protein, carbohydrates and fat

provoke protein-calorie malnutrition (PCM), and when combined with
micronutrient deficiencies, they are among the most important nutritional
problems with hundreds of millions of pregnant women, elderly and young
children particularly affected2. Malnutrition is one of the most important
underlying causes of child mortality in developing countries, particularly during
the first 5 years of life ; the major causes for this are poverty, world conflicts, lack
of education, natural disasters and poor access to health care. PCM usually
manifests early in children between 6 months and 2 years of age and is associated
with early weaning, delayed introduction of complementary foods, a low-protein
diet and severe or frequent infections. Nearly one-third of children in the
developing world are malnourished 2.

Diverse studies have demonstrated that malnutrition increases the risks of

infection and death. The most frequent causes of death in children under 5 years
old are acute diarrhea and acute respiratory infection. Several studies have shown
that malnutrition is frequently causally associated with these deaths. However, as
malnutrition rarely appears as cause of death on death certificates, its impact is
largely underestimated. Increasing evidence suggests that protein-calorie
malnutrition is the underlying reason for the increased susceptibility to infections
observed in these areas 2.

Moreover, certain infectious diseases also cause malnutrition, which can

result in a vicious cycle. Malnutrition and bacterial gastrointestinal and respiratory
infections represent a serious public health problem. The increased incidence and
severity of infections in malnourished children is largely due to the deterioration
of immune function; limited production and/or diminished functional capacity of
all cellular components of the immune system have been reported in malnutrition 2.
In this review, we analyze the cyclical relationship between malnutrition, immune
response dysfunction, increased susceptibility to infectious disease, and metabolic
responses that further alter nutritional status. The consequences of malnutrition
are diverse and included: increased susceptibility to infection, impaired child
development, increased mortality rate and individuals who come to function in
suboptimal ways 1,2
 CHAPTER 2

LITERATURE REVIEW

2.1. Malnutrition

2.1.1 Definition

WHO defines malnutrition as the cellular imbalance between the intake of

nutrients and energy and the bodys demand to ensure growth, maintenance and
specific functions.3 The term malnutrition covers 2 broad groups of conditions.
One is undernutrition - which includes stunting, wasting, underweight and
micronutrient deficiencies or insufficiencies (a lack of important vitamins and
minerals). Another is overweight, obesity and diet-related non-communicable
diseases (such as heart disease, stroke, diabetes and cancer). 3

Malnutrition is defined as a person's nutritional condition is below

average. Toddlers are called malnourished when the body weight by age
(Weight /Age) is <-3 SD and or found clinical signs of marasmus, kwashiorkor
and marasmus-kwashiorkor.4

2.1.2 Epidemiology

The global prevalence of stunting (height-for-age <2 SD) has declined

from an estimated 40% to 26% over the last 20 yr with the greatest reductions
having taken place in Asia. Wasting (weight-for-height <2 SD) affects 8% of
children <5 yr, the prevalence changed little over the past 2 decades. Asia carries
69% of the global burden of underweight children, 58% of the global burden of
stunted children, and 70% of the global burden of wasted children because of the
combination of large population size and high prevalence. 3 From 2007 to 2011,
the proportion of poor people in Indonesia declined from 16.6 to 12.5 per cent but
malnutrition showed no significant reduction (Figure 1). The prevalence of
stunting is especially high, affecting one out of every three children under five
years of age, which is a proportion that constitutes a public health problem
according to the criteria of the World Health Organization (WHO).9
2.1.3 Etiology

Several etiologies for severe malnutrition includes:

1. Food intake

Lack of food intake can be caused by various factors, such as the

unavailability of adequate food, or the wrong diet. The nutritional needs of infants
are water, energy, protein, fat, carbohydrates, vitamins and minerals.
Protein and carbohydrates provides 4 calories per gram, while fat provides 9
calories per gram. The distribution of calories in toddlers in the dietary balance is
15% of protein, 35% of fat, and 50% of carbohydrates. The daily caloric excess of
about 500 calories causes a gain of 500 grams a week.

Most toddlers with severe malnutrition have an inadequate diet, where the
toddler consume meals that does not meet the balanced nutrition diet. Patterns of
food that is said balanced nutrition diet if it contains elements of energy
substances like vegetables and fruit.5

2. Socio-Economic Status

The low economic family, will have an impact. The low quality and
quantity of food consumption is a direct cause of malnutrition in children. Low
socioeconomic conditions can be relate to health problems faced due to ignorance
and inability to overcome the problems. Severely malnourished children generally
live with less nutritious foods.5

3. Maternal education

One factor causing poverty is low education. The low level of education
can affect the availability of food in the family, which further affects the quantity
and quality of food consumption which is the direct cause of malnutrition in
children. So education is needed to obtain information that can improve the
quality of life.

4. Co-existing disease

a. Persistent diarrhea

Persistent diarrhea is a continued episode of diarrhea for 14 days or

more that begins with an acute or bleeding diarrhea (dysentery). This
incidence is often associated with weight loss and non-intestinal
infections. Persistent diarrhea does not include chronic diarrhea or
recurrent diarrhea such as sprue, gluten sensitive enteropathi and Blind
loop disease.5

b. Tuberculosis

Tuberculosis is a disease caused by Mycobacterium tuberculosis,

which is an aerobic bacteria that can live in the lungs or in other organs
that have high oxygen partial pressures. This bacteria is not resistant to
ultraviolet, therefore transmission occurs in the evening. Tuberculosis can
occur in all age groups, both in the lungs and outside the lungs.

c. HIV / AIDS

This viral infection results in a persistent decline in the immune

system, which will lead to immune deficiency. The immune system is
considered deficient when the system no longer perform its function to
protect the body from infections and diseases.5
 The presence of coexisting disease may worsen the state of
nutrition through food intake disorders and increased loss of essential
nutrients. Children who suffer from moderate malnutrition and severe
malnutrition is susceptible to diseases.5

d. Malignancy

Morbidity and mortality rates in patients with malignancy are said

to be high. The mortality rate of malignant patients is not solely due to the
malignancy, but due to the combination of malnutrition with physical and
psychological effects. Severe eating disorder leads to reduced body weight
and nutritional intake, whereas nutritional adequacy is needed to support
the therapeutic process.5

5. Low Birth Weight

Low Birth Weight (LBW) can also be caused by the growth restriction
while in the womb. This is due to the mother's condition or poor nutritional status.
The condition of low birth weight is dependent on the age of pregnancy at birth.
Increased mortality, morbidity, and disabilities of neonatal ad infant are major
factors caused by low birth weight. Malnutrition can occur if long-term LBW.
LBW babies are more susceptible to diseases, especially infectious diseases. This
disease causes toddlers lack of appetite so that food intake into the body becomes
reduced and can cause malnutrition.

2.1.4 Classification of Malnutrition

Based on its clinical manifestations, malnutrition is divided into:

1. Marasmus

Marasmus is one of the most common forms of malnutrition in infants.

Clinical manifestations of marasmus are skinny, thin and rare hair, wrinkled skin
caused by fat under the skin is reduced, old man face, cranky and baggy pants.

Marasmus begins with reduced growth and the occurrence of muscle

atrophy, as well as the reduced of fat under the skin. The body needs energy for
the survival of body tissues. Proteins are also used to meet the energy needs.
Tissue degradation process occurs in calorie deficiency is not only to meet the
energy needs, it is also for glucose synthesis.6

2. Kwashiorkor

Kwashiorkor is a form of severe protein malnutrition, caused by a normal

or high carbohydrate intake and inadequate protein intake. The typical signs of
kwashiorkor include impaired child development, mental changes, in most cases
found mild or severe edema, gastrointestinal symptoms, head hair is easily
uprooted, dry skin, often found hyperpigmentation, liver enlargement, and mild
anemia.

Metabolic disorders can lead to fatty liver and edema. In patients with
protein deficiency, there is no excessive process of tissue catabolism because the
energy supply can be met with sufficient calorie intake. Lack of protein intake will
lead to deficiency of essential amino acids needed. Insufficient carbohydrate
content in the diet will cause the production of insulin to. The reduced production
of albumin by the liver is caused by decreased amino acids in the serum leads to
edema.6

3. Marasmus-Kwashiorkor

Clinical symptoms includes clinical symptoms of marasmus and

kwashiorkor, with weight by age <60% SD WHO-NCHS accompanied by edema,
hair disorders, and skin disorders.4
 Figure 1: Marasmus and kwashiorkor

2.1.5 Measurement of Malnutrition

The determination of malnutrition is based on several methods, includes:
1.Clinical measurements
This method is to know the nutritional status of a child. Clinical
measurements are based on changes that occur and are associated with
nutritional deficiencies. This can be seen in the changes of epithelial tissue
affecting the skin, hair, or eyes.5 For example, toddlers with marasmus are
most likely to have wrinkled skin, whereas in toddlers with kwashiorkor
the skin will appear white or pink.7

2. Anthropometric measurements
This method is carried out by performing several measurements,
including height, weight, and upper arm circumference. Some of these
measurements correspond to the age. Nutritional status not only known by
measuring weight or height according to their age, but also in the form of
indicators that can be a combination of all three.7

Based on weight by age

1. Severely underweight, if weight / age is less than -3 SD.

2. Underweight, if weight / age is -3 SD up to -2SD.

 3. Normal, if weight / age is -2 SD up to 2 SD.

4. Overweight, if weight / age is more than 2 SD.

Based on height measurement (24 months - 60 months) or body

length (0 months - 24 months)

1. Severely stunted, if height / age is less than -3 SD.

2. Stunted, if height /age is -3 SD up to -2 SD.

3. Normal, if height / age is -2 SD up to 2 SD.

4. Tall, if height / age is more than 2 SD.

Based on the measurement of body weight by height or body length

1. Severely wasted if weight / height is less than -3 SD.

2. Wasted if weight / height is -3 SD up to -2 SD.

3. Normal if weight / height is -2 SD up to 2 SD.

4. Obese if weight / height is more than 2 SD.

2.1.6 Pathophysiology of malnutrition

When a childs intake is insufficient to meet daily needs, physiologic and

metabolic changes take place in an orderly progression to conserve energy and
prolong life. This process is called reductive adaptation. Fat stores are mobilized
to provide energy. Later protein in muscle, skin, and the gastrointestinal tract is
mobilized. Energy is conserved by reducing physical activity and growth,
reducing basal metabolism and the functional reserve of organs and by reducing
inflammatory and immune responses. These changes have important
consequences: 8
Development of hypoglycaemia is due to the quantity of stored
glucose in the body is reduced in a malnourished child because of
muscle wasting. In addition, mechanisms for re-establishing
 glucose equilibrium by converting protein and fat reserves into
glucose are impaired. The immune response to infections, which
are common in malnourished children, uses up glucose.
Heat production is less, making the child more vulnerable to
hypothermia.
The kidneys are less able to excrete excess fluid and sodium, and
fluid easily accumulates in the circulation, increasing the risk of
fluid overload.
The heart is smaller and weaker and has a reduced output, and fluid
overload readily leads to death from cardiac failure.
Sodium builds up inside cells due to leaky cell membranes and
reduced activity of the sodium/potassium pump, leading to excess
body sodium, fluid retention, and edema.
Potassium leaks out of cells and is excreted in urine, contributing
to electrolyte imbalance, fluid retention, edema, and anorexia.
Loss of muscle protein is accompanied by loss of potassium,
magnesium, zinc, and copper.

The gut produces less gastric acid and enzymes. Motility is

reduced, and bacteria may colonize the stomach and small
intestine, damaging the mucosa and deconjugating bile salts.
Digestion and absorption are impaired.

Cell replication and repair are reduced, increasing the risk of

bacterial translocation through the gut mucosa.

Immune function is impaired, especially cell-mediated immunity.

The usual responses to infection may be absent, even in severe
illness, increasing the risk of undiagnosed infection.
Red cell mass is reduced, releasing iron which requires glucose and
amino acids to be converted to ferritin, increasing the risk of
hypoglycemia and amino acid imbalances. If conversion to ferritin
 is incomplete, unbound iron promotes pathogen growth and
formation of free radicals.
Micronutrient deficiencies limit the bodys ability to deactivate free
radicals, which cause cell damage. Edema and hair/skin changes
are outward signs of cell damage.
When prescribing treatment it is essential to take these changes in function into
account, otherwise organs and systems will be overwhelmed and death will
rapidly ensue.

2.1.7 Diagnosis

Severe acute malnutrition is defined in these guidelines as the presence of

oedema of both feet or severe wasting (weight-for-height/length <-3SD or mid-
upper arm circumference < 115 mm). No distinction is made between the clinical
conditions of kwashiorkor or severe wasting because their treatment is similar.

Children who are <-3SD weight-for-age may be stunted (short stature) but
not severely wasted. Stunted children who are not severely wasted do not require
hospital admission unless they have a serious illness. 8

The main diagnostic features are:

weight-for-length/height < -3SD (wasted) or
mid-upper arm circumference < 115 mm or
oedema of both feet (kwashiorkor with or without severe wasting).
Children with severe acute malnutrition should first be assessed with a full
clinical examination to confirm whether they have any general danger sign,
medical complications and an appetite.

Children with severe acute malnutrition with loss of appetite or any

medical complication have complicated severe acute malnutrition and should be
admitted for inpatient care. Children who have a good appetite and no medical
complications can be managed as outpatients.
2.1.8 Initial assessment
Assess for general danger signs or emergency signs and take a history
concerning:9
recent intake of food and fluids
usual diet before the current illness
breastfeeding
duration and frequency of diarrhoea and vomiting
type of diarrhoea (watery/bloody)
loss of appetite
family circumstances
cough > 2 weeks
contact with TB
recent contact with measles
known or suspected HIV infection/exposure.

Figure 2: Child with severe acute malnutrition oedema

On examination, look for:
shock: lethargic or unconscious; with cold hands, slow capillary refill
(>3s), or weak (low volume), rapid pulse and low blood pressure.

signs of dehydration
 severe palmar pallor

bilateral pitting oedema

eye signs of vitamin A deficiency:

dry conjunctiva or cornea, Bitot spots

corneal ulceration
keratomalacia

Table 3: Pitting oedema on dorsum of foot

When pressure is applied for a few seconds, a pit remains after the finger is
removed. 9

2.1.9 Management

Table 1: The 10 steps of treatment for severe acute malnutrition.

 Table 4 shows the 10 steps of treatment, which are separated into 2 phases
referred to as stabilization and rehabilitation. These steps apply to all clinical
forms and all geographic locations, including North America and Europe. The aim
of the stabilization phase is to repair cellular function, correct fluid and electrolyte
imbalance, restore homeostasis, and prevent death from the interlinked triad of
hypoglycemia, hypothermia, and infection. The aim of the rehabilitation phaseis
to restore wasted tissues (i.e., catch-up growth). It is essential that treatment
proceeds in an ordered progression and that the metabolic machinery is repaired
before any attempt is made to promote weight gain. Pushing ahead too quickly
risks inducing the potentially fatal refeeding syndrome. Caregivers bring
children to health facilities because of illness, rarely because of their malnutrition.

A common mistake among healthcare providers is to focus on the illness

and treat as for a well-nourished child. This approach ignores the deranged
metabolism in malnourished children and can be fatal. Such children should be
considered as severely malnourished with a complication, and treatment should
follow the 10 steps. Two other potentially fatal mistakes are to treat edema with a
diuretic and to give a high-protein diet in the early phase of treatment.8
Table 2: Emergency treatment in severe malnutrition
Emergency treatment summarizes the therapeutic directives for
malnourished children with shock and other emergency conditions. Note that
treatment of shock in these children is different (less rapid, smaller volume,
different fluid) from treatment of shock in well-nourished children. This
difference is because shock from dehydration and sepsis often coexist and are
difficult to differentiate on clinical grounds. Thus one has to be guided by the
response to treatment: children with dehydration respond to IV fluid whereas
those with septic shock will not respond. Since severely malnourished children
can quickly succumb to fluid overload, they must be monitored closely.8
Table 3: Treatment for stabilization phase
 Table 6 summarizes the therapeutic directives for stabilization steps 1-7.
Giving broad-spectrum antibiotics and feeding frequent small amounts of F75 (a
specially formulated low-lactose milk with 75 kcal and 0.9 g protein per100 mL to
which potassium, magnesium, and micronutrients are added), will reestablish
metabolic control, treat edema, and restore appetite. The parenteral route should
be avoided; children who lack appetite should be fed by nasogastric tube, as
nutrients delivered within the gut lumen help in its repair.9
F75 is also available commercially in which maltodextrins replace some
of the sugar and to which potassium, magnesium, minerals, and vitamins are
already added. Dehydration status is easily misdiagnosed in severely wasted
children, as the usual signs (such as slow skin pinch, sunken eyes) may be present
even without dehydration. Rehydration must therefore be closely monitored for
signs of fluid overload. Serum electrolyte levels can be misleading because of
sodium leaking from the blood into cells and potassium leaking out of cells.
Keeping the intake of electrolytes and nutrients constant allows systems to
stabilize more quickly than adjusting intake in response to laboratory results.6
Rehabilitation phase is the signals for entry to this phase are reduced/minimal
edema and return of appetite.
A controlled transition over 3 days is recommended to prevent the
refeeding syndrome. After the transition, unlimited amounts should be given of
a high-energy, high protein milk formula such as F100 (100 kcal and 3 g protein
per 100 mL), or ready-to-use therapeutic food (RUTF), or family foods modified
to have comparable energy and protein contents. To make the transition, for 2
days replace F75 with an equal volume of F100 and then increase each successive
feed by 10 mL until some feed remains uneaten (usually at around 200
mL/kg/day). After the transition, give 150-220 kcal/kg/day and 4-6 g
protein/kg/day and continue to give potassium, magnesium, and micronutrients.
Add iron (3 mg/kg/day). If breastfed, encourage continued breastfeeding. Children
with severe malnutrition have developmental delays, so loving care, structured
play, and sensory stimulation during and after treatment are essential to aid
recovery of brain function.9
2.2 Pneumonia

2.2.1. Definition

Pneumonia is an infection or inflammation of the lower airway in the lung

parenchyma and consolidation of the alveolar space caused by various causes such
as bacteria, viruses and fungi. Symptoms usually occur with fever, cough,
breathlessness / increased frequency of breathing, chest wall retraction, nasal lobe
breathing and sometimes cyanosis.10

Pneumonia is common in children but is more common in infants and

early childhood, clinically pneumonia occurs as a primary disease or complication
from other diseases. According to WHO pneumonia is divided into two based on
the location of the acquired pneumonia is Community Acquired Pneumonia
(CAP) and Hospitalized Acquired Pneumonia (HAP) .10

2.2.2. Etiology

The causes of pneumonia are bacteria, viruses, fungi, chemical exposure

or physical damage from the lungs, as well as indirect effects of other diseases.
Common bacteria that cause pneumonia are Streptococcus and Mycoplasma
pneumonia, while the virus that causes pneumonia is adenovirus, rhinovirus,
influenza virus, respiratory syncytial virus (RSV) and the influenza virus. 11

In developing countries pneumonia is more commonly caused by

bacteria than viruses. While in developed countries, the virus became the most
common cause. The pattern of pneumonia-causing microorganisms usually
changes according to the age distribution of the patient. Many factors can increase
the risk of pneumonia such as decreased immunity due to certain diseases or long
hospitalized.11

2.2.3. Pathogenesis
Pneumonia can occur due to the influence of 3 factors including: host,
microorganisms that attack (agent), and interaction environment (environment).
Various modes of transmission of pneumonia include: through droplet can be
caused by Streptococcus pneumonia, whereas infection in ventilator use is caused
by Enterobacter sp and P. aeruginosa.13,14,15
 In a healthy condition or host immunity is good then there is no growth
of microorganisms (agents) in the lung because of the mechanism of defense of
the lungs are functioning properly. Disease arises when there is an imbalance
between the immune system (host), microorganism (agent) and environment
(environment). When the pulmonary defense mechanism does not perform the
function properly then the agent can go to the alveoli through the respiratory tract
causing inflammation in the walls of the alveoli and surrounding tissue.16
The course of pneumonia disease is divided into several stages, as follows: 13
1. Stage I (4 - 12 hours first / congestive)
This stage is also called hyperemia, referring to the initial inflammatory
response taking place in the newly infected area. The accumulation of fluid
between the capillaries and the alveolus increases the distance that oxygen and
carbon dioxide must travel through, which will lead to the disruption of the
gas exchange process resulting in a decrease in oxygen saturation of
hemoglobin.
2. Stage II (next 48 hours)
This stage is also called red hepatization. This occurs when the alveolus
is filled by red blood cells, exudate and fibrin produced by the host as part of
an inflammatory reaction. The affected lobes become solid due to the buildup
of leukocytes, erythrocytes and fluids so that the lung color becomes red and
the touch feels like a liver. At this stage the air inside the alveoli is so minimal
that there is no such that the patient will look congested. The stage is short, ie
for 48 hours.14
3. Stage III (3 - 8 days)
The next stage is also called hepatisasi gray. This is because white blood
cells colonize the infected lung region. At this time the fibrin deposits
accumulate throughout the injured area and phagocytosis of cell remains. At
this stage the erythrocytes begin to be reabsorbed, the lobes still remain solid
due to the presence of fibrin and leukocytes, the red color turns pale gray and
blood capillaries are no longer congested.15
 4. Stage IV (7 - 12 days)
At this stage there is a decrease in the immune response and
inflammation so that it is named as a stage of resolution. Remnants of fibrin
cells and exudate the lysis and absorbed by the macrophages so that the tissue
returns to its original structure.17

2.2.4. Diagnosis
Examination used to diagnose pneumonia include from clinical symptoms,
physical examination and investigation as follows:11,12
2.2.4.1 Anamnesis
Symptoms of viral and bacterial pneumonia are sometimes not
very different. In children under 5 years of age, symptoms are usually
cough with phlegm sputum or yellow may be accompanied by difficulty
breathing, with or without fever, pneumonia is usually diagnosed from
rapid breathing or retraction during inhalation. Wheezing and high fever
are more common in viral pneumonia. In more severe circumstances,
patients usually can not eat and drink, not conscious, hypothermia, and
seizures.11
Clinical symptoms of severe pneumonia can be divided into
two, mild and moderate severe symptoms. Mild symptoms include fever
<38.5oC, mild respiratory depression, normal appetite, no vomiting,
oxygen saturation 95%. Severe symptoms include fever 38,5oC,
takipneu, tachycardia, difficulty breathing, decreased appetite or loss of
appetite, vomiting, signs of dehydration, oxygen saturation <95%

2.2.4.2 Physical examination

Findings on physical examination can determine the degree of
weight of pneumonia. On physical examination can be found fever,
tachypnea, retraction (subcostal, intercostal, suprasternal), breathing nose,
head nodding, cyanosis, tracheal deviation, signs of consolidation such as:
reduced chest expansion; increased vocal fremitus, dim sound localized to
percussion; a weakened breathing sound, bronchial or bronchovicular,
rhonki, wheezing can be heard in auscultation.12
 2.2.4.3 Supporting Examination
1. Laboratory examination
Complete blood examination of pneumonia is commonly
obtained by leukocytosis with neutrophils that predominate on arithmetic
types. Leukocytes> 30,000 103 / L with neutrophil dominance leading to
bacteria Streptococcus pneumonia. Thrombocytosis> 500,000 103 / L is
characteristic of bacterial pneumonia. Infections caused by viruses usually
cause thrombocytopenia. Blood cultures are specific but only positive in
10-15% of cases.15
2. Radiological examination
Chest X-ray is the principal investigation to make the diagnosis. AP /
lateral thoracic photo aims to determine the location of anatomy in the
lung. Description patchy infiltrate and there is a picture of bronchogram
water is a picture on thoracic photos of patients with pneumonia.14
3. Microbiological examination
Microbiological examination can be done through a swab of throat
specimens, nasopharyngeal secretions, sputum, tracheal aspiration, pleural
puncture, blood, lung aspiration and bronchial rinses. This examination is
difficult both in terms of technical and cost.14,16

2.2.5. Management
The treatment of pneumonia depends on the stage and the age of the patiens such
as follows.16
1. Oxygen
Oxygen therapy is given when there are signs of hypoxemia; anxiety,
cyanosis and others. At the age <2 years is usually given 2 liters / minute
while at age> 2 years can be given oxygen up to 4 liters / minute.

2. Liquid and nutritious food

Liquids: the simplest composition is Dextrose 5%, other compositions
depending on need, amount of 60-70% total requirement, some sources
stated can be given according to maintenance needs.
 Food: if not peroral, may be considered intravenous administration such
as amino acids and fatty emulsions.
3. Antibiotics / Antiviral
Based on the WHO 2014 guidelines, antibiotics in children suffering from
pneumonia, as follows: 11
Recommendation for children with rapid breathing without chest wall
retraction or general alarm should be given amoxicillin: at least 40mg /
kg / dose twice daily (80mg / kg / day) for five days.
Recommendation for children aged 2-59 months with a chest wall
retraction should be given amoxicillin 40mg / kg / dose twice daily for
five days.
Recommendation for children 2-59 months with chest retraction or
severe pneumonia should be given parenteral ampicillin (or penicillin)
and gentamicin as first-line treatment. Ampicillin: 50 mg / kg, or
benzyl penicillin: 50 000 units per kg IM / / IV every 6 hours for five
days and Gentamicin: 7,5 mg / kg IM / IV once daily for five days.
Ceftriaxone is used as second-line treatment in children with severe
pneumonia after failure in first-line treatment.
Recommendation for ampicillin (or penicillin if ampicillin is not
available) plus gentamicin or ceftriaxone are recommended as first-line
antibiotics for infants infected with HIV and for children under 5 with
severe pneumonia.
Recommendation for empirical cotrimoxazole treatment for jirovecii
Pneumonia (formerly Pneumocystis carinii) pneumonia (PCP) is
recommended as an adjuvant treatment for HIV-infected infants aged 2
months to 1 years with chest retraction or severe pneumonia. Empirical
cotrimoxazole treatment for jirovecii pneumonia Pneumonia (PCP) is
not recommended for children infected with HIV and 1 year of age
with severe pneumonia.
Symptomatic
The treatment depends on the symptom or the patients complaint.
 a. Antipyretics are given when there is hyperpireksia. Avoid
acetosal because it can aggravate acidosis.
b. Mukolitik / ekspektorans.
c. Antitusives are generally not given.
d. Anticonvulsants; may be considered if the seizure is not due to
hypoxemia; can be choralhydrate 50mg / kg / day (divided into
3 doses) or diazepam 0.5-0.73 / kg / times, IM / IV
e. Corticosteroids

2.3. Human Immunodeficiency Virus (HIV)

2.3.1 Definition

HIV (Human Immunodeficiency Virus) is a type of retrovirus that attacks

the human immune system and can cause a condition called AIDS. HIV viruses
are classified into classes of lentivirus or retroviridae. This virus is genetically
made up of RNA that depends on the enzyme reverse transcriptase to be able to
infect cells, including humans, and cause slow pathological abnormalities. This
virus consists of 2 groups, namely HIV-1 and HIV-2. Each group has more
subtypes, and each subtype evolves rapidly through mutations. Among the two
groups, the most abnormal and more virulent in the world is the HIV-1 group.
 The HIV virus attacks white blood cells in charge of preventing infection
in our bodies. These white blood cells are primarily lymphocytes that have CD4
as a marker located on the surface of lymphocyte cells. Therefore the decrease in
CD4 values in the human body indicates a decrease in white blood cells or
lymphocytes that should play a role in dealing with infections that enter the
human body. In people with a good immune system, CD4 values range from
1400-1500. Whereas in people with impaired immune systems (people infected
with HIV) the CD4 cell count gets worse.

AIDS stands for Acquired Immuno Deficiency Syndrome, which means a

collection of symptoms or syndromes due to decreased immunity caused by HIV
infection. The human body has immunity to protect itself from outside attacks
such as germs, viruses, and diseases. AIDS weakens or damages the body's
defense system, so eventually there are various other diseases18.

2.3.2 Epidemiology

The first case of AIDS in Indonesia was reported from Bali in April 1987.
The sufferer was a Dutch tourist who died at Sanglah Hospital due to a secondary
infection of his lungs. Until the end of 1990, the increase in HIV / AIDS cases
doubled.

Since the middle of 1999 began to see a sharp increase due to the use of
injecting narcotics. The worrying fact is that these drug users are mostly teenagers
and young adults who are a productive age group. At the end of March 2005, 6789
cases of HIV / AIDS were reported.

By the end of December 2008, the number of cases has reached 16,110
AIDS cases and 6,554 HIV cases. While the number of deaths due to AIDS
recorded has reached 3,362 people. Of all the AIDS patients, 12,061 sufferers
were men with the highest spread through sex. 19

2.3.3 Etiology and Pathogenesis

HIV is considered a virus that causes AIDS. A unique morphological

feature of HIV is the presence of a cylindrical nucleotide in the mature virus. This
virus contains 3 genes needed for replication of retroviruses (gag, pol, env). There
are more than 6 additional viral genes which are important in the pathogenesis of
the disease.

Once the virus enters the body the primary target is CD4 lymphocytes
because the virus has an affinity for the CD4 surface molecule. The virus has the
ability to transfer their genetic information from RNA to DNA using an enzyme
called reverse transcriptase. CD4 lymphocytes function to coordinate a number of
important immunological functions. This loss of function causes a progressive
immune response disorders.

After the primary infection, there is a 4-11 day period between mucosal
infection and early detectable viremia for 8-12 weeks. During this time, the virus
is widespread throughout the body and reaches the lymphoid organs. At this stage
there has been a decrease in the number of CD4 T-cells. Immune responses to HIV
occur 1 week to 3 months after infection, plasma viremia decreases, and CD4 cell
levels rise again but are unable to exclude infections completely. This clinical
latency can last for 10 years. During this period there will be increased viral
replication. It is estimated that about 10 billion HIV particles are produced and
destroyed every day. The half-life of the virus in plasma is about 6 hours, and the
viral life cycle averages 2.6 days. Infected T-CD4 lymphocytes have a half-life of
1.6 days. Because of the rapid proliferation of this virus and the binding HIV
reverse transcriptase error rate, it is estimated that every nucleotide of the HIV
genome may mutate on a daily basis.

Eventually the patient will suffer constitutional symptoms and a real

clinical illness such as opportunistic infections or neoplasms. Higher viral levels
can be detected in the plasma during further infection stages. Opportunistic
infections can occur because people with HIV have a decreased endurance to a
very low level, so that some types of microorganisms can attack certain parts of
the body.20

2.3.4 Mode of transmission

 HIV cells are primarily in human body fluids. Potential fluids containing
HIV are blood, semen, vaginal fluid and breast milk. Transmission of HIV can
occur in a variety of ways: sexual contact, infective blood or infectious contact
(needle, razor blade, and knife), mother to child during pregnancy, delivery and
breastfeeding (breast milk).

2.3.5 Clinical Symptoms

Clinical symptoms consist of 2 symptoms of major (common) and minor

symptoms (not common):

Major symptoms:

a. Weight loss decreased by more than 10% in 1 month

b. Chronic diarrhea lasting more than 1 month
c. Prolonged fever for more than 1 month
d. Decreased awareness and neurological disorders
e. Dementia / HIV encephalopathy
Minor symptoms:

a. Cough persists for more than 1 month

b. Generalized dermatitis
c. Herpes Zoster multisegmental
d. Oropharyngeal candidiasis
e. Progressive chronic herpes simplex
f. Generalized lymphadenopathy
g. Cytomegalo virus retinitis

Clinical symptoms of HIV / AIDS are divided into several phases.

a. Initial phase

At the beginning of the infection, there may be no symptoms and

signs of infection. But sometimes there are flu-like symptoms such as
fever, headache, sore throat, rash and swollen lymph nodes. Although they
 have no symptoms of infection, people with HIV / AIDS can transmit the
virus to others.

b. Advanced phase

Patients will remain free of symptoms of infection for 8 or 9 years

or more. But along with the development of viruses and destruction of
immune cells, people with HIV / AIDS will begin to show chronic
symptoms such as enlarged lymph nodes (often a typical symptom),
diarrhea, decreased weight, fever, cough and short breathing.

c. The final phase

During the final phase of HIV, which occurs about 10 years or

more after infection, more severe symptoms begin to arise and the
infection will end in a disease called AIDS.21

2.3.6 Treatment

Provision of anti-retroviral (ARV) has caused the health conditions of

patients to be much better. Emphasis on viral replication leads to decreased
production of cytokines and viral proteins that can stimulate growth. ARV drugs
consist of several classes such as nucleoside reverse transcriptase inhibitors,
nucleotide reverse transcriptase inhibitors, non-nucleotide reverse transcriptase
inhibitors and protease inhibitors. These drugs only play a role in inhibiting viral
replication but cannot eliminate the already developed virus.

Vaccines against HIV can be given to uninfected individuals to prevent

both infection and disease. Also, consider the possibility of providing therapeutic
HIV vaccine, in which an HIV-infected person will be given treatment to
encourage an anti-HIV immune response, decrease the number of virus-infected
cells, or delay the onset of AIDS. However, the development of vaccines is
difficult because HIV rapidly mutates, is not expressed on all infected cells and is
not completely excised by the host immune response after primary infection. 17

2.3.7 Prevention
 Ways to prevent HIV / AIDS are: abstinence, meaning not (delaying)
having sex, Stay faithful to a partner / fidelity, no multiple sex partners, and use of
Condoms at any sexual intercourse that is at risk of contracting the HIV virus or
other sexually transmitted diseases (STDs). Education is another essential way to
prevent the spread of HIV.

2.3.8 HIV in Children

The annual number of new HIV infections among children (0-14 years)
has almost halved since 2010. HIV infections among children have been averted
due to the provision of antiretroviral medicines (ARVs) to women living with HIV
during pregnancy and breastfeeding. Despite this significant progress, the number
of children becoming newly infected with HIV remains high. This is mainly due
to the lack of knowledge and access to ARVs. 120,000 children died due to AIDS-
related illnesses every year. This equates to 328 deaths every day. Millions more
children are indirectly affected by the impact of the HIV epidemic on their
families and communities. Regular HIV testing, treatment, monitoring and care
for children living with HIV can enable them to live long and fulfilling lives.17

2.3.9 Children at risk of HIV infection

The majority of children living with HIV are infected via mother-to-child
transmission (MTCT), during pregnancy, childbirth or breastfeeding. This is
sometimes referred to as vertical transmission or parent-to-child-transmission.
It is possible to stop MTCT of HIV, as long as the mothers have access to
preventing mother-to-child transmission (PMTCT) methods during pregnancy,
delivery and breastfeeding.

Breastfeeding is now responsible for the majority of MTCT. When

formula feeding is not a viable option, women can greatly reduce the risk of
transmitting HIV to their child at this stage if they exclusively breastfeed and are
on ART. However, only 49% of women continued to take ARVs while
breastfeeding, compared to 62% of women who took ARVs during pregnancy and
delivery. This highlights the urgent need for education about the importance of
continuing treatment post-birth.18

HIV infection in medical/healthcare settings

Although very rare today, HIV infection can occur in medical

settings. For example, through needles that have not been sterilized or
through blood transfusions where infected blood is used.

Orphans and vulnerable children

Children feel the greatest impact from the loss of their parents or
older relatives due to HIV related illnesses. An estimated 13.4 million
children and adolescents (0-17 years) worldwide had lost one or both
parents to AIDS as of 2015. Children orphaned by AIDS, or who are living
with sick caregivers, continue to face an increased risk of physical and
emotional abuse as compared with other children in, including other
orphans. This increases these childrens vulnerability to HIV. 23

2.3.10 HIV and its impact on malnutrition

There is a growing recognition that HIV and malnutrition interact in

complex ways that heighten vulnerability to and worsen severity of each
condition. Malnutrition in a Patient with HIV/AIDS may occur because of a
variety of factors such as

Macronutrients (protein, carbohydrates and fat) and HIV/AIDS

Patients with HIV/AIDS often eat less, this is usually because of loss
of appetite. In addition to underlying HIV infection, many opportunistic
infections contribute to this by causing nausea, vomiting, malaise, and fever.
Infections such as esophageal candidiasis may cause a sore mouth or pain
during eating can also decrease food intake, and this may occur silently in
children. After an acute or severe episode of illness, appetite may improve and
there is a chance to recover. The need for food at this time is much greater, but
people rarely have enough food if HIV occurs in a background of poverty.

Children and adults with HIV and AIDS may have less access to food
because of stigma or a decreased ability to provide food for themselves.
Stigma may lead to job loss, or being cast out from the shelter of family or
community. People also lose their jobs because they are too ill to work.
Farmers who are ill may not be able to grow enough food to feed themselves.
Having HIV & AIDS also causes resources to be directed away from food to
healthcare. People may have to choose between paying for medicine or for
food.

Changes in absorption

When food is available, it may be poorly absorbed in patients with

HIV and AIDS. Intestinal malabsorption and nutrient loss is common. While
severe diarrhea and malabsorption may be due to opportunistic infections or
intestinal parasites such as cryptosporidiosis, some of the absorption problems
appears to be a consequence of HIV infection itself. The HIV virus damage
the intestinal villi, and inflammation can damage gut tissue and reduce
absorption. Enzymes in the intestinal mucosa involved with metabolism and
absorption can also be less active. These changes in the GI track seem to affect
the bodys ability to absorb dietary fat and carbohydrates.

Changes in metabolism

HIV infection and replication also affects metabolism in a many ways.

Some of the metabolic effects may be mediated by the bodys inflammatory
immune response, especially the production of cytokines. Cytokines are
chemical messengers and growth factors produced by lymphocytes in the
blood to help direct the inflammatory immune process, and this increases the
nutrient requirements of the host. In adults there is a 10% increase in resting
energy expenditure (or the resting metabolic rate/RMR).Any energy that HIV
misdirects is likely to have a big impact on children because they require a
higher proportion of energy for growth and development. There are also
endocrine/ hormonal changes in patients with HIV and AIDS such as
hypogonadism, (reduced or absent of secretion of hormones from the sex
glands). Testosterone levels in particular may be depressed accompanied by a
substantial loss of muscle or lean body mass. Patients who are ill normally
lose fat stores first, followed by a loss of lean body mass. But in HIV patients,
there are clear changes in protein synthesis and breakdown both in the
immune cells, the liver and the muscle.

Micronutrients (vitamins and minerals) and HIV Infection

In addition to food, people with HIV may need additional

micronutrients. People with serious infections or diseases, may have altered
intake, absorption and metabolism of various micronutrients. These
deficiencies in turn can weaken the immune system and increase the risk of
infection. Micronutrient supplementation can improve health. For example,
vitamin A supplementation reduces mortality from a variety of causes in
children under 5. The effects of micronutrient deficiencies and/or
supplementation on HIV disease are complex.

There is clear evidence that micronutrient status affects both

susceptibility to and progression of HIV infection as well as general health,
pregnancy outcomes, and growth in children. Micronutrients also interact with
drug therapy, affecting the bioavailability, effectiveness, and/or safety of
medicines.

In severe cases, micronutrient deficiency leads to a complex known as

NAIDS or nutritionally acquired immunodeficiency syndrome which, like
AIDS, increases susceptibility to secondary infections. In a person with HIV,
NAIDS may contribute to CD4 cell decline and increase the risk of
progression to AIDS and death. In addition, poor micronutrient status also
leads to oxidative stress, which has been directly shown to increase HIV
replication. 22
2.4 Anaemia

2.4.1 Definition

The condition of having a lower-than-normal number of red blood cells or

quantity of haemoglobin. Anaemia diminishes the capacity of the blood to carry
oxygen. Patients with anaemia may feel tired, fatigue easily, appear pale,
develop palpitations, and become short of breath. Children with chronic anaemia
are prone to infections and learning problems. The main causes of anaemia are
bleeding, haemolysis (excessive destruction of red blood cells), underproduction
of red blood cells (as in bone marrow diseases), and underproduction of normal
haemoglobin (as in sickle cell anaemia and in iron deficiency anaemia). Women
are more likely than men to have anaemia because of menstrual blood loss. In
children, anaemia is most commonly due to insufficient iron in the diet. Anaemia
is also often due to gastrointestinal bleeding caused by medications, including
such common drugs as aspirin and ibuprofen.24

2.4.2 Causes

There are more than 400 types of anaemia, which are divided into three groups:
Anaemia caused by blood loss
Anaemia caused by decreased or faulty red blood cell production
Anaemia caused by destruction of red blood cells

2.4.2.1 Anaemia Caused by Blood Loss

Red blood cells can be lost through bleeding, which often can occur
slowly over a long period of time, and can go undetected. This kind of chronic
bleeding commonly results from the following:

Gastrointestinal conditions such as ulcers, hemorrhoids, gastritis
(inflammation of the stomach), and cancer

Use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin
or ibuprofen, which can cause ulcers and gastritis 25

2.4.2.2 Anaemia Caused by Decreased or Faulty Red Blood Cell

Production
With this type of anaemia, the body may produce too few blood cells or
the blood cells may not function correctly. In either case, anaemia can result.
Red blood cells may be faulty or decreased due to abnormal red blood cells or
a lack of minerals and vitamins needed for red blood cells to work properly.
Conditions associated with these causes of anaemia include the following:
Sickle cell anaemia
Iron-deficiency anaemia
Vitamin deficiency
Bone marrow and stem cell problems
Other health conditions
 Sickle cell anaemia is an inherited disorder that. Red blood cells
become crescent-shaped because of a genetic defect. They break down rapidly,
so oxygen does not get to the body's organs, causing anaemia. The crescent-
shaped red blood cells can also get stuck in tiny blood vessels, causing pain.
Iron-deficiency anaemia occurs because of a lack of the mineral iron in
the body. Bone marrow in the center of the bone needs iron to make
hemoglobin, the part of the red blood cell that transports oxygen to the body's
organs. Without adequate iron, the body cannot produce enough hemoglobin
for red blood cells. The result is iron-deficiency anaemia. This type of anaemia
can be caused by 25:
An iron-poor diet, especially in infants, children, teens, vegans, and
vegetarians
The metabolic demands of pregnancy and breastfeeding that deplete a
woman's iron stores
Menstruation
Frequent blood donation
Endurance training
Digestive conditions such as Crohn's disease or surgical removal of part
of the stomach or small intestine
Certain drugs, foods, and caffeinated drinks

Vitamin-deficiency anaemia, this type anaemia may occur when

vitamin B12 and folate are deficient. These two vitamins are needed to make
red blood cells. Conditions leading to anaemia caused by vitamin deficiency
include:
Megaloblastic anaemia: Vitamin B12 or folate or both are deficient
Pernicious anaemia: Poor vitamin B12 absorption caused by conditions
such as Crohn's disease, an intestinal parasite infection, surgical
removal of part of the stomach or intestine, or infection with HIV
 Dietary deficiency: Eating little or no meat may cause a lack of vitamin
B12, while overcooking or eating too few vegetables may cause a folate
deficiency.
Other causes of vitamin deficiency: pregnancy, certain medications,
alcohol abuse, intestinal diseases such as tropical sprue and celiac
disease

Bone marrow and stem cell problems may prevent the body from
producing enough red blood cells. Some of the stem cells found in bone
marrow develop into red blood cells. If stem cells are too few, defective, or
replaced by other cells such as metastatic cancer cells, anaemia may result.
Anaemia resulting from bone marrow or stem cell problems include: 24
Aplastic anaemia occurs when there's a marked reduction in the number
of stem cells or absence of these cells. Aplastic anaemia can be
inherited, can occur without apparent cause, or can occur when the
bone marrow is injured by medications, radiation, chemotherapy, or
infection.
Thalassemia occurs when the red cells can't mature and grow properly.
Thalassemia is an inherited condition that typically affects people of
Mediterranean, African, Middle Eastern, and Southeast Asian descent.
This condition can range in severity from mild to life-threatening; the
most severe form is called Cooley's anaemia.
Lead exposure is toxic to the bone marrow, leading to fewer red blood
cells. Lead poisoning occurs in adults from work-related exposure and
in children who eat paint chips, for example. Improperly glazed pottery
can also taint food and liquids with lead.

Anaemia of chronic disease. Certain diseases such as cancer,

HIV/AIDS, rheumatoid arthritis, kidney disease, Crohn's disease and other
chronic inflammatory diseases can interfere with the production of red blood
cells.

2.4.2.3 Anaemia Caused by Destruction of Red Blood Cells

 When red blood cells are fragile and cannot withstand the routine stress
of the circulatory system, they may rupture prematurely, causing hemolytic
anaemia. Hemolytic anaemia can be present at birth or develop later.
Sometimes there is no known cause. Known causes of hemolytic anaemia may
include:
Inherited conditions, such as sickle cell anaemia and thalassemia
Stressors such as infections, drugs, snake or spider venom, or certain
foods
Toxins from advanced liver or kidney disease
Inappropriate attack by the immune system (called hemolytic disease of
the newborn when it occurs in the fetus of a pregnant woman)
Vascular grafts, prosthetic heart valves, tumors, severe burns, exposure
to certain chemicals, severe hypertension, and clotting disorders
In rare cases, an enlarged spleen can trap red blood cells and destroy
them before their circulating time is up.

2.4.3 Risk Factors

Anaemia can occur in people of all ages and race, males and females.
However, there are certain factors that raise the risk for anaemia:

Women of childbearing age - due to menstruation

Pregnancy and childbirth - due increased demands of iron, women

should supplement with folic acid

Preterm infants

Children aged 1-2

Individuals with poor diets, low in vitamins, mineral, and iron

 Blood loss from surgery or injury

Long-term or serious illnesses, such as AIDs, diabetes, kidney disease,

cancer, rheumatoid arthritis, heart failure, and liver disease

A family history of inherited anaemias, such as sickle cell anaemia

Intestinal disorders-affects absorption of nutrients

2.4.4 Sign and Symptoms

The most common symptom of anaemia, regardless of type, is a feeling

of fatigue and a lack of energy. Other common symptoms of anaemia may
include:

Paleness of skin

Fast or irregular heartbeat

Shortness of breath

Chest pain

Headache

Light-headedness

In mild cases of anaemia, individuals have little to no symptoms. Some

forms of anaemia can have specific symptoms unique to their type:

Aplastic anaemia - fever, frequent infections, and skin rashes.

Folic acid deficiency anaemia - irritability, diarrhea, and a smooth

tongue.

Hemolytic anaemia - jaundice, dark colored urine, fever, and abdominal

pains.
 Sickle cell anaemia - painful swelling of the feet and hands, fatigue,
and jaundice.

2.4.5 Diagnosis

There are basically three different causes of anaemia: blood loss,

decreased or faulty red blood cell production, or destruction of red blood cells.
Blood tests will not only confirm the diagnosis of anaemia, but also help point to
the underlying condition. Tests might include:

Complete blood count (CBC), which determines the number, size,
volume, and hemoglobin content of red blood cells.

Blood iron level and serum ferritin level, the best indicators of the
body's total iron stores.

Levels of vitamin B12 and folate, vitamins necessary for red blood cell
production.

Special blood tests to detect rare causes of anaemia, such as an immune
attack on the red blood cells, red blood cell fragility, and defects of
enzymes, hemoglobin, and clotting.

Reticulocyte count, bilirubin, and other blood and urine tests to
determine how quickly the blood cells are being made or if a hemolytic
anaemia, where the red blood cells have a shortened life span. 25

2.4.6 Treatment

There is a range of treatments for anaemia, all ultimately aimed at

increasing the red blood cell count which in turn increases the amount of oxygen
the blood carries. Depending on the type of anaemia, the treatment has to match
the cause:

Iron deficiency anaemia - iron supplements or dietary changes. If the

condition is due to loss of blood, the bleeding must be found and
stopped.

Vitamin deficiency anaemias - treatments include dietary supplements

and B-12 shots.
 Thalassemia - blood transfusions, folic acid supplements, removal of
the spleen and, sometimes, blood transfusions and bone marrow
transplants.

Anaemia of chronic disease - this is anaemia associated with a serious,

chronic underlying condition; there are no specific treatments. The
focus is on the underlying condition.

Aplastic anaemia - blood transfusions or bone marrow transplants.

Sickle cell anaemia - administering oxygen, pain relief, and

intravenous fluids. Other treatments could include antibiotics, folic acid
supplements, and blood transfusions. A cancer drug known as Droxia or
Hydrea is also used.

Hemolytic anaemias - avoiding suspect medication, treating infections,

immunosuppressant drugs. Plasmapheresis (blood-filtering) might be
necessary in some cases.

If the anaemia is caused by nutritional deficiencies, a change to an iron-

rich diet can help alleviate the symptoms. The following foods are high in iron 26:

Iron-fortified cereals and breads

Dark-green leafy vegetables, for instance, curly kale and watercress

Pulses and beans

Brown rice

White and red meats

Nuts and seeds

Fish

Tofu

Eggs
 Dried fruits, including apricots, raisins, and prunes

2.4.7 Discussion

Childrens anaemia can be classified by the size of their red blood cells.
There are 3 types of classifications which are Microcytic anaemia, Normocytic
anaemia dan Macrocytic Anaemia. Microcytic anaemia is condition where the red
blood cells are smaller than normal and the most common cause is iron deficiency.
Normocytic anaemia is a condition where the red blood cells are in normal size
and the most common causes are due to some chronic diseases. Macrocytic
anaemia is where the red blood cells are larger than normal and it may be caused
by vitamin B12 deficiency. 24

And in this case, the patient is diagnosed as Normocytic anaemia. This is

based on the laboratorium results where the red blood cell is normal in size. The
cause of this disease is may due to chronic disease which is in this case is the HIV
stg IV. The treatment for this patient is treating the cause, which is the HIV
infection.

In conclusion, anaemia is a frequent complication of HIV/AIDS infection. The

severity of anaemia depends on the clinical and immunologic stage of the disease,
worsening in presence of most opportunistic infections or low CD4 cell count, and
is especially highly prevalent in patients with low body mass index. HAART
produces an improvement of hemoglobin levels. The treatment of patients with
anaemia should target its cause, but it is important to know that early start of
HAART may prevent anaemia or reduce its severity. 26
 CHAPTER III
CASE REPORT

3.1 Patient Identity

Name : IKWAK
Age : 8 years 11 months
Sex : Male
Address : Br Saba Blahbatuh, Gianyar
Religion : Hindu
Ethnic group : Bali / Indonesia
Education : Primary School
Medical record : 17036108
Admission : August 21st 2017, 16.03

3.2 History
Chief complaint
Shortness of Breath

Current Medical History

Patient referred from Sanjiwani Hospital, Gianyar with diagnosis HIV
infection stadium III + Severe Malnutrition Marasmus condition III Transition
Phase. Patient complained of shortness of breath (SOB) since 2 days before
admitted to the hospital (BATH) in the form of fast breathing and chest wall
retraction. SOB is said to be worsen day by day and does not reduce with the
change of position. SOB is not accompanied with abnormal sounds. Bluing of lips
and finger tips was denied.
Patient also complained of cough with difficulty of sputum production,
with white sputum without blood since 1 month BATH. Cough is said to be on
and off despite consuming medications obtained from a General Practitioner.
Patient is also said to have fever since 2 days BATH but temperature was not
measured by the parents. Patient complained of loose stools since 2 weeks
BATH with stools yellow in colour and a little pulpy. Prescence of blood, mucus
and acid odour from stool was denied. Frequency of defecation is said to be 3
times a day with volume of about cup each time. Vomiting was denied.
Patient is said to have lost weight since 5-6 months ago where the patient was
intially 17 kg and has continously decreased til now. Weight loss is
accompanied with decrease of appetite and weakness of body.
At the time of examination, fever (-), cough (-), vommiting (-), loose
stools (-). White patches is found on the tongue of patient.

Past Medical History

About 1 year ago, patient suffered from throat pain accompanied with white
plaque on the tongue and lips. Patient was hospitalized in Sanjiwani Hospital,
Gianyar and was diagnosed with HIV infection since July 2016. The patient
started receiving ARV treatment on 28 September 2016 til October 2016 and then
dropped out from medication til now.

Medication History
Patient visited a General Practitioner and received medication for his cough but
forgot the name of the medicine. Patient has been given F100 110 ml, Resomal
110 ml every loose stool, Zinc 20mg, Nystatin drop 1 ml every 6 hours in
Sanjiwani Hospital, Gianyar from 18 August to 21 August 2017.

Family History
No family member suffer similar complaints as the patient. The patients mother
was tested HIV positive 1 year ago and is currently on ARV treatment. Patients
father has died in 2010. Patients siblings were tested negative for HIV.

Social History
Patient is the third child from 3 siblings.

Immunization History

Patient has received BCG, Polio 4x, Hepatitis B 4x, DPT 3x, Measles 1x
immunizations.
Allergy, Surgery and Transfusion History

Patient is said to have no history of drug or food allergy. Patient has not
undergone surgery or had transfusions before.

Labor History
Patient was born on due by normal delivery assisted by midwife. Weight at birth
was 2900 grams , body length at birth and head circumference is said to be
forgotten. Patient cried spontaneously after birth without congenital defects.

Nutritional History
Breastmilk : 0 days til 24 months = 8-10x/day 60 ml each time
Formula milk : Not given
Porridge : 4 months now = 3x/day portion each time
Steamed rice : 12 months now = 3x/day 5 spoon each time
Adult food : 18 months - now = 3x/day 1 packet of rice each time

Growth and Development History

Head straightening : 1 month

Body turning : 20 days

Siting : 6 months

Crawling : 7 months

Standing : 12 months

Walking : 12 months

Speech : 18 months

- Patient has stopped schooling since 6 months ago due to his illness. Patient
was said to be in mid second class of primary school before he stopped
schooling. He was said to be a very obedient boy with many friends before
he fell ill.
3.3 Physical Examination

Present Status

General appearance : Moderate Illness

HR : 114 times / minute
RR : 38 times / minute
Axial Temperature : 37,10C

Nutritional status

Weight : 11 kg
Length of Body : 106.5 cm
Ideal weight : 17.5 kg
Head Circumference : 43 cm
Upper Arm Circumference : 10.5 cm
Standard Upper Arm Circumference : 17 cm
% of Upper Arm Circumference : 61,8%
Waterlow : 66,7% (severe malnutrition)
CDC Growth Chart :
- Weight ~ age: below the 5th percentile
- Height ~ age: below the 5th percentile
- Weight - height: below the 5th percentile

General Status

Head : normocephali, Old man Face (+)

Eyes : sunken eyes, pale conjunctiva - / -, jaundice - / -, pupil reflex + / +

isokor

ENT

- Ear : Auricula dextra: no abnormalities found

Auricula sinistra: no abnormalities found.

 - Nose : Nostril breathing (-), cyanosis (-), rhinnorea (-), epistaxis (-)

- Throat : Hyperemic pharynx (-), tonsils T1 / T1 hyperemic (-)

Mouth : cyanosis (-), oral candidiasis tongue (+)

Neck

Inspection : Lump (-)

Palpation : Enlarged Glands (+) multiple enlargement, region colli

dextra and sinistra with measurements of 0,2 0.5 cm,
meningeal sign (-)

Thorax

- Heart

Inspection : ictus cordis visible in the 5th ICS, to the left of the median
line
Palpation : ictus cordis palpable in the 3rd 5th ICS, to the left of the
medial line
Auscultation : S1S2 single regular murmur (-)

- Lungs
Inspection : symmetrical, chest wall retraction (+) intercostal

Palpation : symmetrical chest movement

Auscultation : vesicular + / +, rhonchi - / -, wheezing - / -

Abdomen

Inspection : distension (-)

Auscultation : bowel sound (+) normal

Palpation : Liver palpable 3cm below arcus costae and 3 cm below

proc. xiphoideus,

sharp, smooth surface, rebound tenderness (-)

Spleen not palpable

Percussion : tympanic

Genitalia : no abnormalities
Extremities

Warm :+ + edema : - -

+ + - -

3.4 Laboratory Investigations

Complete Blood Count (21/8/2017)

WBC : 4,38 x 103 K/L (N= 6,0 14,0)

HGB : 8,73 gr/dl (N= 12,0 16,0)

HCT : 27.14 % (N= 36,0 49,0)

MCV : 78,11 fL (N= 78,0 102,0)

MCH : 25,11 (N= 25,0 35,0)

MCHC: 32,15 (N= 31 36)

PLT : 106.4 x 103 K/L (N= 140,0 440,0)

Blood Gas Analysis (26/8/2017)

pH : 7,44 (N= 7,35-7,45)

pCO2 : 38,4 (N= 35,0-45,0)

pO2 : 161,5 (N= 80,0-100,0)

HCO3 : 25,2 (N= 22.0-26,0)

TCO2 : 26,4 (N= 24,0-30,0)

SO2 : 99,1 (N= 95-100)

Blood Chemistry Test (21/8/ 2017)

ALP : 328 (N= 0-300)

SGOT : 50,4 (N= 11,00-33,00)

SGPT : 33,80 (N= 11,00-50,00)

Total Protein : 6,7 (N= 6,00-8,00)

Albumin : 3,0 (N= 3,50-5,20)

Globulin : 3,7 (N= 3,20-3,70)

BS : 96 (N= 60,00-100,00)

Na : 137 mmol/L (N= 135,00-145,00)

K : 3,3 mmol/L (N= 3,50-5,10)

Cl : 98,7 mmol/L (N= 94,00-110,00)

Ca : 8,4 mg/dL (N 9,20-11,00)

Feces Test (22/8/2017)

Macroscopic: Microscopic:

- Color : yellow - leucocyte: -

- Consistency : dilute - erythrocyte: -

- Mucus : positive - amoeba: -

- Blood : negative - worm egg: -

- others: Fat (+)

Chest X-Ray (21/8/2017)

Abnormalities found : presence of infiltrate at right parahiler and paracardial,

silhouette sign (+).

Result:
Suitable with Pneumonia appearance (to be correlated with clinical symptoms)

3.5 Clinical Diagnosis

1. Pneumonia
2. Severe Malnutrition - Marasmus condition III Transition phase
3. HIV Infection stadium IV
4. Moderate anemia normochromic normocytic ec. chronic disease

3.6 Management
 - Nasal O2 2 liter/min

- Ampicillin 50 mg/kg every 6 hours iv

- Gentamicin 7.5mg/kg/day every 24 hours iv

- Paracetamol 10mg/kg every 4 hours when temp. >38oC

- 10 steps of malnutrition management :

I. Prevent/Treat Hypoglycemia

II. Prevent/Treat Hypothermia

III. Prevent/Treat Dehydration

IV. Correct imbalance of Electrolyte

V. Treat infections

VI. Correct deficiencies of micronutrients

VII. Start cautious feeding

VIII. Rebuild wasted tissue

IX. Provide loving care and play

X. Prepare for follow up

3.7 Monitoring

- Vital sign

- Sp02

- Eating tolerance

- Fluid balance

- Overfeeding syndrome

- Refeeding syndrome
 CHAPTER 4

DISCUSSION
4.1 Malnutrition
A brief comparison about malnourishment based on theory and case report

The comparisons are made based on three key aspects of the medical field which
are:

Anamnesis
Physical examination
Diagnostic test

4.1.1 Anamnesis results based on theory

In theoretical terms, there are several patients who are at higher risk of
malnourishment, among known risk factors include

a. Lack of food intake/inadequate diet

b. Low socio-economic status
c. Poor Maternal education
d. Co-existing disease
Persistent diarrhea
Tuberculosis
HIV/AIDS
Malignancy
Low Birth Weight

From the case report, among the risk factors that is related to the diagnosis
are the presence of an underlying disease; HIV which eventually becomes a
co-existing disease. Apart from that, based on anmenesis, it is found that the
patient comes from a family with low socio-economic status and a poorly
educated mother.

4.1.2 Physical examination

a. A clinical measurement can be done to test for nutritional deficiencies

b. Anthropometric measures is performed by measuring height, weight
and upper arm circumference
 - Based on weight by age

1. Severely underweight, if weight / age is less than -3 SD.

2. Underweight, if weight / age is -3 SD up to -2SD.

3. Normal, if weight / age is -2 SD up to 2 SD.

4. Overweight, if weight / age is more than 2 SD.

- Based on height measurement (24 months - 60 months) or body

length (0 months - 24 months)

1. Severely stunted, if height / age is less than -3 SD.

2. Stunted, if height /age is -3 SD up to -2 SD.

3. Normal, if height / age is -2 SD up to 2 SD.

4. Tall, if height / age is more than 2 SD.

- Based on the measurement of body weight by height or body length

1. Severely wasted if weight / height is less than -3 SD.

2. Wasted if weight / height is -3 SD up to -2 SD.

3. Normal if weight / height is -2 SD up to 2 SD.

4. Obese if weight / height is more than 2 SD.

From the case, patient is present with an Old man face and sunken eyes. On the
thoracal examination, upon inspection and palpation, it was found that ictus cordis
was visible in the 5th ICS to the left of them medial line. Ictus cordis was palpable
in the 3rd 5th ICS.

From the nutritional status, results show

Weight : 11 kg
Length of Body : 106.5 cm
 Ideal weight : 16.5 kg
Head Circumference : 43 cm
Upper Arm Circumference : 10.5 cm
Standard Upper Arm Circumference : 17 cm
% of Upper Arm Circumference : 61,8%
Waterlow : 66,7% (severe malnutrition)

4.1.3 Diagnostic Test

The main diagnostic features are:
weight-for-length/height < -3SD (wasted) or
mid-upper arm circumference < 115 mm or
oedema of both feet (kwashiorkor with or without severe wasting).
Based on the assessment performed on the patient,
CDC Growth Chart :
o Weight ~ age: below the 5th percentile
o Height ~ age: below the 5th percentile
o Weight - height: below the 5th percentile
o BB / TB: below the 5th percentile,
o Head Circle ~ age: below the 5th percentile

4.1.4 Management
 10 steps of malnutrition management :

I. Prevent/Treat Hypoglycaemia

II. Prevent/Treat Hypothermia

III. Prevent/Treat Dehydration

IV. Correct imbalance of Electrolyte

V. Treat infections V

VI. Correct deficiencies of micronutrients

VII. Start cautious feeding

IX. Provide loving care and play

X. Prepare for follow up

4.2 Pneumonia
A brief comparison about pneumonia based on theory and case report
The comparisons are made based on three key aspects of the medical field which
are:

Anamnesis
Physical examination
Diagnostic test
4.2.1 Anamnesis results based on theory

In theoretical terms, patients with pneumonia are usually present with

cough and phlegm accompanied by shortness of breath, with fever as well.
Pneumonia is usually diagnosed from rapid breathing or retraction during
inhalation. Wheezing may also be found in several cases. In more severe
circumstances, patients usually cant eat and drink, not conscious,
hypothermia, and seizures.

From the case report, patient came in with a chief complain of

shortness of breath two days before admission to the hospital. Shortness of
breath was presented in the form of fast breathing and is said to worsen day by
day and did not reduce with a change of position. Patient also complained of
cough with difficulty of sputum expulsion where upon expulsion, the sputum
is white without blood one month before admission to hospital. On top of that,
patient was said to have fever two days before admission to hospital but the
temperature was not measured by the parents.

4.2.2 Physical Examination

Based on theory, patient will normally be present with chest wall

retraction, a decrease of vocal fremitus, weakening of breath sound and
rhonchi. In rare cases, meningeal signs, chest pain and friction rub can be
found. And most commonly the presence of fever can be noted. Severe
symptoms include fever 38,5oC, tachypneu, tachycardia, difficulty breathing,
decreased appetite or loss of appetite, vomiting, signs of dehydration, oxygen
saturation <95%.
From the case, upon physical examination, it is found that the patient
had a rapid heart rate of 166 x/min meanwhile the normal rate should be
between 70 to 110 x/min. Patient also found to have mild fever with an axial
 temperature of 37.1oC. Upon thoracal examination, an intracostal chest wall
retraction was present.

4.2.3 Diagnostic Test

The most necessary test that need to be included in confirming the
diagnosis of pneumonia is the chest X-ray. AP / lateral thoracic photo aims to
determine the location of anatomy in the lung. An appearance of patchy
infiltrate is found in the affected lobe of the lung. From complete blood count,
patient will either be present with leucocytosis or leucopenia whereby
leucopenia indicates a bad prognosis.
Upon a blood test, it was found that the patient had a low count of white
blood cell which is 4.38K/L (leucopenia).

4.2.4 Management

THEORY CASE REPORT

Supportive therapy: 02 nasal canule, 2 litres per minute

Oxygen, enteral/parenteral nutrition
Antibiotic Ampicilin 50mg/kg + Gentamycin
7.5 mg/kg/day

Age (years) Energy (Kkal/kg/day) Protein (g)

0 0.5 120 2.5

0.5 - 1 110 2.0
1-3 100 1.5
4-6 90 1.0
7-9 80 1.0
10 - 12 70 0.9

4.2.5 Pneumonia and Malnourishment

 There are
several risk
factors that lead to malnourishment. In cases of poverty insufficient income, will
reduce the quality of living conditions. It will then become pathogen load prone
increasing risks of various infections, such as pneumonia. Pneumonia specifically
targets the lung parenchyma and affects the alveolar spaces which will then reduce
immunity. Patient suffering from pneumonia infection tend to have low appetite
due to their general health status. This will then cause lack of nutrients which then
contributes to weight loss causing growth faltering. When growth faltering occurs,
there is an imbalance in demand and supply of nutrients by the body. Lack of
nutrients absorption will cause altered metabolism hence reducing immunity level,
resulting in infections such as pneumonia

4.3 Human Immunodeficiency Virus (HIV)

 A brief comparison about HIV based on theory and case report
The comparisons are made based on three key aspects of the medical field which
are:

Anamnesis
Physical examination
Diagnostic test

4.3.1 Anamnesis results based on theory

In theoretical terms, patients with HIV are usually present with clinical
symptoms which can be further divide into major and minor symptoms which
are as below:

Major symptoms:

a. Weight loss decreased by more than 10% in 1 month

b. Chronic diarrhoea lasting more than 1 month

c. Prolonged fever for more than 1 month

d. Decreased awareness and neurological disorders

e. Dementia / HIV encephalopathy

Minor symptoms:

a. Cough persists for more than 1 month

b. Generalized dermatitis

c. Herpes Zoster multisegmental

d. Oropharyngeal candidiasis

e. Progressive chronic herpes simplex

f. Generalized lymphadenopathy

g. Cytomegalo virus retinitis

 From the case report, from the major symptoms, patient is present with a
weight loss of more than 10% whereby patient had initial weight of 17kg and has
continuously decreased with a current of 11kg. patient also complained of having
loose yellow stool. Frequency of defecation said to be approximately 3 times a
day with a volume of cup each time. From the minor symptoms, patient
complained of cough since 1 month before admission to hospital. Cough is said to
persist despite medication obtained from a general practitioner. Patient also
complained of having history of throat pain accompanied by white plaque on the
tongue and lips since one year ago. Patient was diagnosed with HIV infection in
July 2016.

4.3.2 Physical Examination

Based on theory, patient will normally be present in the beginning of infection,
with fever, headache, sore throat, rash and swollen lymph nodes. In advanced
phase patients will remain free of symptoms of infection for 8 or 9 years or more.
But along with the development of viruses and destruction of immune cells,
people with HIV / AIDS will begin to show chronic symptoms such as enlarged
lymph nodes (often a typical symptom), diarrhoea, decreased weight, fever, cough
and short breathing. During the final phase of HIV, which occurs about 10 years
or more after infection, more severe symptoms begin to arise and the infection
will end in a disease called AIDS.
From the case, upon physical examination, it is found that the patient has oral
candidiasis on the tongue and upon palpation on the neck, enlarged glands were
present with a description of multiple enlargement in the colli region of both sides
with measurements of 0.2-0.5 cm. a pulse examination an increase in heartbeat,
166x/min.

4.3.3 Diagnostic Test

The most necessary test that need to be included is HIV DNA, HIV RNA
and CD4 count. As for the patient the confirmation test was done a year ago in
July 2016 and results were positive for HIV.

4.3.4 Management
 THEORY CASE REPORT
Anti-retroviral (ARV) Patient had a history of treatment drop out
since October 2016.

4.3.5 Hiv and Malnourishment

There is a growing recognition that HIV and malnutrition interact in
complex ways that heighten vulnerability to and worsen severity of each
condition. Malnutrition in a patient with HIV/AIDS may occur because of a
variety of factors such as

Macronutrients (protein, carbohydrates and fat) and HIV/AIDS

Patients with HIV/AIDS often eat less, this is usually because of loss of
appetite. In addition to underlying HIV infection, many opportunistic
infections contribute to this by causing nausea, vomiting, malaise, and fever.
Infections such as esophageal candidiasis may cause a sore mouth or pain
during eating can also decrease food intake, and this may occur silently in
children.

Changes in absorption

When food is available, it may be poorly absorbed in patients with HIV

and AIDS. Intestinal malabsorption and nutrient loss is common. While severe
diarrhea and malabsorption may be due to opportunistic infections or intestinal
parasites such as cryptosporidiosis, some of the absorption problems appears
to be a consequence of HIV infection itself. The HIV virus damage the
intestinal villi, and inflammation can damage gut tissue and reduce absorption.
Enzymes in the intestinal mucosa involved with metabolism and absorption
can also be less active. These changes in the GI track seem to affect the bodys
ability to absorb dietary fat and carbohydrates.

Changes in metabolism
 HIV infection and replication also affects metabolism in many ways. Some
of the metabolic effects may be mediated by the bodys inflammatory immune
response, especially the production of cytokines. Cytokines are chemical
messengers and growth factors produced by lymphocytes in the blood to help
direct the inflammatory immune process, and this increases the nutrient
requirements of the host. In adults there is a 10% increase in resting energy
expenditure (or the resting metabolic rate/RMR). There are also endocrine/
hormonal changes in patients with HIV and AIDS such as hypogonadism,
(reduced or absent of secretion of hormones from the sex glands). Testosterone
levels in particular may be depressed accompanied by a substantial loss of
muscle or lean body mass. Patients who are ill normally lose fat stores first,
followed by a loss of lean body mass. But in HIV patients, there are clear
changes in protein synthesis and breakdown both in the immune cells, the
liver and the muscle.

Micronutrients (vitamins and minerals) and HIV Infection

In addition to food, people with HIV may need additional micronutrients.

People with serious infections or diseases, may have altered intake, absorption
and metabolism of various micronutrients. These deficiencies in turn can
weaken the immune system and increase the risk of infection. Micronutrient
supplementation can improve health. For example, vitamin A supplementation
reduces mortality from a variety of causes in children under 5. The effects of
micronutrient deficiencies and/or supplementation on HIV disease are
complex.
4.4 Anemia
A brief comparison about anemia based on theory and case report
The comparisons are made based on three key aspects of the medical field which
are:

Anamnesis
Physical examination
Diagnostic test

4.4.1 Anamnesis results based on theory

In theoretical terms, patients with anemia are usually present with the
common complaints of feeling tired and fatigue easily and also accompanied
with shortness of breath. Patients will also complain of having a loss of
appetite along with history of frequent illness mostly infections. Apart from
that, patient will also complain of having chest pain, headache and light-
headedness.
From the case report, it is found that through the anamnesis the patient had
been suffering weakness and loss of appetite since 5 to 6 months ago.
4.4.2 Physical Examination
Based on theory, patient will normally be present with paleness without a
bleeding manifestation.
From the case report, manifestation of paleness was not found.

4.4.3 Diagnostic Test

The most necessary test that needs to be included in confirming the

diagnosis of anaemia is the complete blood count where a decrease value of
Haemoglobin will be found. Other tests that can be conducted alongside
include blood smear, observing the blood iron level and serum ferritin level.
From the case report, it is found that the patient had a low haemoglobin level
of 8.73 g/dl which falls below the normal range of 12-16 g/dl.

4.4.4 Management
 THEORY CASE REPORT
Causative agent Chronic disease as an Patient suffers from
underlying factor HIV infection stadium
IV
Iron Supplement Ferrous sulphate tablet -
in the case iron
deficiency anaemia
Blood Transfusion Rarely needed. Only -
given when Hb is less
than 4g/dl.

Patient suffers from HIV infection stadium IV which contributed to the

manifestation of anaemia. Thus the line management chosen to handle this
was to treat underlying chronic disease itself. This is because anaemia is a
frequent complication of HIV/AIDS infection. The severity of anaemia
depends on the clinical and immunologic stage of the disease, worsening in
presence of most opportunistic infections or low CD4 cell count, and is
especially highly prevalent in patients with low body mass index. HAART
produces an improvement of haemoglobin levels. The treatment of patients
with anaemia should target its cause, but it is important to know that early start
of HAART may prevent anaemia or reduce its severity.

4.4.5 Malnutrition and Anaemia

Theoretically, nutritional deficiencies act as one of the factor that causes
anaemia.
 Diagram 1: Causes of anaemia
In normal human body, a low intake of iron can cause less iron absorption
into the system. Iron is an important component of haemoglobin that transports
oxygen from lungs throughout the body, if there isnt sufficient amount of iron,
one cant make enough healthy oxygen carrying red blood cell which then causes
anaemia. Hence, the symptoms of exhaustion, fatigue and a decrease of immune
system capability.

CHAPTER V
CONCLUSION
Malnutrition can make a person more susceptible to infection, and
infection also contributes to malnutrition, which causes a vicious cycle. An
inadequate dietary intake leads to weight loss, lowered immunity, mucosal
damage, invasion by pathogens, and impaired growth and development in
children. A sick person's nutrition is further aggravated by diarrhea,
malabsorption, loss of appetite, diversion of nutrients for the immune response,
and urinary nitrogen loss, all of which lead to nutrient losses and further damage
to defense mechanisms. These, in turn, cause reduced dietary intake. In addition,
fever increases both energy and micronutrient requirements. HIV-AIDS and
influenza, for example, have mortality rates proportionate to the degree of
malnutrition. Here, we focused on describing the interactions between
malnutrition and immune system dysfunction and the determinants that provoke
increased susceptibility to gastrointestinal and bacterial respiratory infections. In
synergy with infection, malnutrition contributes to 56% of all childhood deaths
worldwide2. The causes of malnutrition are multiple and complex and infections
are a common precipitating factor. Acute gastrointestinal and respiratory
infections are the most important causes of high morbidity and mortality among
malnourished children and malnutrition is an important associated factor in these
death. The studies described within this review provide evidence that the
combination of several defective immune mechanisms synergistically inhibits the
development of an adequate host immune response.

The same goes to our case based discussion patient that was referred to
Sanglah Hospital with diagnosis HIV infection stage III + Malnutrition
Marasmus condition III Transition Phase. In the patient, it is found out that the
patient suffered from persistent diarrhea two weeks before admission to the
hospital with pulpy yellow stool. Frequency of bowel movement is said to be 3
times a day with volume of about cup each time. Patient is said to have lost
weight since 5-6 months ago where the patient was intially 17 kg and has
continously decreased till now. Weight loss is accompanied with decrease of
appetite and body weakness.Apart from that, patient seems to be suffering from
co-existing disease which is HIV-AIDS which was diagnosed one year ago.
Patient stopped the medication for his underlying disease since October 2016
which contributed to the drastic weight loss, decrease of appetite and body
weakness that leads to malnutrition. Besides that, the patient is diagnosed as
Normocytic anaemia. This is based on the laboratory results where the red blood
cell is normal in size. The cause of this disease is may due to chronic disease
which is in this case is the HIV stg IV. The treatment of patients with anaemia
should target its cause, but it is important to know that early start of HAART may
prevent anaemia or reduce its severity.

If we are to aspire to a future in which malnutrition is not longer a serious

global health issue we must raise awareness and work towards solutions to all
three subcategories, not just one. Undernutrition, obesity/overweight and
micronutrient related malnutrition during childhood all have downstream affects
on the health of the individual which can be prevented through access to a
nutritious and balanced diet as well as an active lifestyle.