1. PEM causes widespread pathological changes throughout the body, particularly affecting the gastrointestinal tract, liver, pancreas, muscles, skin, heart, central nervous system, and immune system. 2. In the gastrointestinal tract, the mucosa becomes atrophic and villi are infiltrated with plasma cells in both the small and large intestines. 3. The liver is enlarged, pale and fatty in kwashiorkor due to triglyceride deposition, while fatty liver is absent in marasmus.

1. Pathological changes in PEM

2. GIT CHANGES
• UPPER GIT CHANGES:-
• Mucosa atrophic and shiny
• Gums are frequently affected
• Necrotic ulcer seen k/a NOMA
• Oral thrush may present
• Tongue papillae flattened
• Salivary gland changes
• Parotid gland enlarged d/t
1. Inspissation of secretion
2. Hyperplasia of gland
3. Acute parotitis

3. LOWER GIT CHANGES
• ATROPHY OF MUCOSA AND VILLI
• INFILTRATION WITH PLASMA CELLS
• COLUMNAR CELLS ARE REPLACED BY CUBOIDAL
CELLS
• PANETH CELLS ARE REDUCED
• BRUSH BORDER ENZYMES (DISACCHARIDASE)
DEFICIENT
• HOOK WORM INFESTATION
• RECTAL PROLAPSE

4. LIVER CHANGES
• Visceral protein component severely affected in
Kwashiorkar
• FATTY LIVER occurs mainly in Kwashiorkar
• D/T deposition of triglyceride
• Liver enlarged , pale and firm in consistency
• Fat accumulation absent in marasmus

5. Fatty liver

6. Changes in Pancreas
• It reduced to cord like tissue
• Acini and acinar cells are reduced
• Zymogen granules disappear
• Varying degree of duct proliferation
seen

7. Endocrinal changes
• Exocrine pancreatic secretion
decreases
• Glucagon,insulin secretion decreases
• Growth hormone increases
• Thyroid involution and fibrosis
• Adrenal gland atrophied and thin
• Cortisol increase catechol unaltered

8. Changes in muscles
• Somatic component i.e protein in skeletal
muscles more severely affected in marasmus
• Muscles wasted
• Severe depletion of protein from non collagen
fibers
• Hyalinisation , absent striation ,vacuolation of
myofibrils
• Catabolism in muscle mass d/t reduction in cell
size

9. Hair and Nail changes
• Cysteine and copper low in hair
• Transverse ridges in nail d/t growth
cessation

10. Skin changes
• It is mainly d/t atrophy and pigmentary
disturbance
• Epidermis is thin ,hyperkeratosis and
desquamation
• Nitrogen content of skin depleted
• Tyrosine level decreases in flaky paint
dermatitis

11. Flaky paint dermatitis

12. Changes in heart
• Heart small in atrophic
• C.O ,systolic pressure ,pulse pressure
decreases
• Heart thin walled ,pale ,flabby d/t
atrophy of muscle fibre

13. C.N.S changes
• Myelinisation in white matter impaired
• Cerebral atrophy
• Decrease number of neuron
• Decrease lipid, cholesterol ,muramic
acid

14. PERIPHERAL NERVES
• Nerve conduction decreases mainly in
kwashiorkar
• Degenerative changes seen in anterior
horn cells

15. Respiratory system
• Secondary infective changes may
present d/t decrease immunity.

16. LYMPH NODE
• Lymphoid atrophy more marked in
kwashiorkar
• Depletion of lymphocytes
• Loss of germinal centers in lymph node
of mesentry, axilla, tonsil, spleen,
appendix
• Tonsils become small in size

17. Haematopoietic system
• Bone marrow becomes hypoplastic d/t
decrease number of red cell precursors
• Following type of anemia seen
1. IDA-microcytic hypochromic
2. Folic acid deficiency –megaloblastic
• Other deficiency- copper,zinc,vitamins
A,E,K
• Increase LDH in platelet leads to
prolonged bleeding time and purpura

18. Bony changes
• Slowing of growth of bones at the ends
of long bone
• Osteoporosis and delay in ossification
• Lamellar hypoplasia seen in teeth

19. Kidney changes
• Kidney atrophies
• Focal areas of calcification seen
• Cloudy swelling of epithelial cells of
PCT and DCT seen

20. Immune system
• CMI decreases
• Immunoglobulin synthesis increases
more in kwashiorkar
• Complement factor level decreases