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A 42-year-old woman with AIDS and pulmonary tuberculosis presents to Mulago Hospital in Kampala, Uganda, complaining of weakness.

The patient presents complaining of several weeks of generalized weakness and fatigue. She notes poor appetite and significant weight loss (she is not able to quantify, but her clothes no longer fit) during the past 2 months. She also reports intermittent subjective fevers. She treated herself for malaria a few weeks ago but did not have any improvement in her symptoms. She is having frequent, loose, watery stools and very infrequent urination. She also complains of numbness and tingling in her feet. She has been too weak to get out of bed and she was carried to the hospital by family members.

• AIDS (most recent CD4 count: 110 cells/µL); patient was diagnosed as HIV positive 2 years ago and started on first-line antiretroviral therapy (ART) 2 months ago

• Pulmonary tuberculosis: diagnosed on acid-fast bacilli (AFB) staining of sputum smears; currently in the continuation phase of therapy

• History of oral candidiasis

• Zidovudine, lamivudine, nevirapine

• Ethambutol and isoniazid (completed 4 months of 8-month regimen)

• Trimethoprim-sulfamethoxazole

• Multivitamin, ferrous sulfate, folic acid, vitamin B6

The patient's daughter and husband died of AIDS. She is the primary caretaker of her 3 grandchildren, who share her 2-room mud house that has no electricity. She completed primary school education and used to earn a living by selling secondhand clothing, but has not been able to work for the past year because of illness. She uses a device to purify her water supply, which she obtains from a nearby well. She denies smoking or alcohol consumption.

• General: pleasant, cachectic woman lying quietly on the ground on bedding that her family provided

• Vital signs: temperature--38.1ºC; heart rate--113 beats per minute; blood pressure--85/50; respiratory rate--18 breaths per minute

• Anthropometric measurements: weight--34 kg; height--151 cm; body mass index (BMI)--15; mid-upper arm circumference (MUAC)--160 mm

• Head: dry and brittle hair, marked alopecia; nonicteric sclerae, pale conjunctiva; temporal muscle wasting; glossitis; no thrush or oral ulcerations

• Neck: shotty lymphadenopathy

• Chest: lungs clear to auscultation bilaterally

• Heart: no jugular venous distension, tachycardic but regular; normal S1, S2; no S3

• Abdomen: decreased bowel sounds and mild abdominal distention; palpation revealed no tenderness or hepatosplenomegaly

• Back: no decubitus ulcers

• Extremities: trace edema bilateral lower extremities

• Neurological: length-dependent decreased sensation in both feet; decreased biceps and patellar deep tendon reflexes

• Skin: dry, scaly

The patient's weight loss, weakness, fatigue, low-grade fever, and symptoms of vitamin deficiencies (peripheral neuropathy, edema) suggest an underlying diagnosis of malnutrition with protein loss. The question remains as to the etiology of her malnutrition. Possible categories (with significant overlap) include:

• General: cachexia, anemia

• Decreased intake:
  
  

  • Decreased access to or availability of food

  • Anorexia
    
    

    • Systemic illness: hepatitis, congestive heart failure

    • Dysphagia: esophagitis (cytomegalovirus, herpes simplex virus, Candida)

• Hypermetabolic states:
  
  

  • AIDS

  • Tropical infectious diseases: malaria, pneumococcal infection, leishmaniasis, hookworm, schistosomiasis, nocardiosis, Ebola hemorrhagic fever, Marburg hemorrhagic fever

  • AIDS-associated infectious diseases: disseminated Mycobacterium avium complex

  • Disseminated tuberculosis (medication nonadherence, drug resistance)

  • Malignancy: lymphoma, leukemia, invasive cervical cancer, disseminated Kaposi sarcoma

• Nutrient loss:

• Diarrheal illnesses, intestinal parasites: cryptosporidiosis, microsporidiosis, isosporiasis, bacteria, invasive amebiasis

• Hemoglobin level was 6 gm/dL

• Stool studies were negative for ova and parasites; cultures were negative for bacteria

• Thin and thick smears were negative for malaria parasites

• Sputum smears were negative for AFB (3 tests)

• Chest X ray was negative (no evidence of congestive heart failure, tuberculosis, or other pulmonary infection)

Based on the patient's history, physical examination, and available studies, a diagnosis of malnutrition was made. According to the World Health Organization (WHO), severe malnutrition in adults is defined by the presence of 3 criteria: edema, weight-for-height index below 70% or MUAC <160 mm, and BMI <16.

The patient received albendazole for empiric treatment of intestinal worms, amoxicillin for empiric treatment of bacterial infections, and oral rehydration therapy and 3-phase nutritional supplementation according to WHO guidelines. Two weeks later, at the time of discharge, her weight had increased to 38 kg and she was able to ambulate without assistance.

The treating team felt that other diagnoses had been excluded, based on the patient's history, the physical examination, and results of available studies. Because the patient responded to the rehydration and refeeding therapy, and did not require other treatments in order to improve, her admission was deemed secondary to malnutrition.

The patient was seen 2 weeks after she was discharged from the hospital at a home visit. The patient continued to note poor appetite. She denied experiencing fever, dysphagia, nausea, vomiting, abdominal pain, or diarrhea. A community health worker confirmed her report of 100% compliance with her tuberculosis medications and ART.

Upon further questioning, it became apparent that the patient had poor access to food despite her enrollment in the United Nations' World Food Program upon starting ART 2 months earlier. As a client of the Reach Out clinic in Kampala, the patient receives daily food supplementation through the U.N. program. The food supplementation for people receiving ART and tuberculosis therapy amounts to 1,048 kcal per day. This includes 150 g of cereal/grains, 40 g of beans, and 100 g of a corn/soya blend fortified with micronutrients. Additionally, a clinician, accompanied by a community health worker, makes weekly home visits to check on the patient's weight. In spite of food supplementation, the patient has made minimal improvement in her weight, probably because she has been sharing her supplement with her extended family members (immediate family members are provided supplementation).

Briefing: Malnutrition