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Introduction <p>Kwashiorkor, an edematous protein-energy malnutrition, is rare in adults in high-income countries. It manifests with hypoalbuminemia, edema, and effusions, often mimicking venous or hepatic congestion. Triggers include chronic illness, psychiatric disease, substance use, or restrictive diets. A low serum-ascites albumin gradient (SAAG) supports malnutrition-related third spacing.</p> Case Presentation <p>A 29-year-old man with poorly controlled type 1 DM and polysubstance use presented with progressive anasarca, ascites, and pleural effusions. Laboratory evaluation revealed profound hypoalbuminemia (nadir, 1.3&#xa0;g/dL) and anemia. Diagnostic paracentesis demonstrated low-SAAG ascites (SAAG &lt; 1.1&#xa0;g/dL) with low ascitic protein (&lt; 2&#xa0;g/dL), excluding portal hypertension. CTV raised concern for IVC thrombosis, but contrast venography was negative. Prompt exclusion of IVC thrombosis was critical to guide anticoagulation and avoid unnecessary intervention. Alternative etiologies, including nephrotic syndrome, pancreatitis-related ascites, and protein-losing enteropathy, were considered but were less consistent with the overall clinical, laboratory, and imaging findings. Nutritional assessment revealed markedly reduced protein intake and clinical features consistent with severe protein–calorie malnutrition.</p> Conclusions <p>Adult kwashiorkor should be considered in unexplained edema and hypoalbuminemia. Low SAAG ascites warrants evaluation for malnutrition. BMI may be misleading due to fluid overload; a full nutritional assessment is essential. Severe hypoalbuminemia likely contributed to venous thromboses.</p>

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Third Spacing, Low-Protein Low-SAAG Ascites, and Venous Thrombosis: A Case of Adult Kwashiorkor in a Resource-Rich Country with Literature Review

  • 期刊论文

  • 发表日期：

    2026年3月30日

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  • Abdalhakim Shubietah,
  • Hossam Salameh,
  • Ana Cristina Proano,
  • Sara Bernardez-Lai,
  • Qasem Salah,
  • Ariel Katz

摘要

Introduction

Kwashiorkor, an edematous protein-energy malnutrition, is rare in adults in high-income countries. It manifests with hypoalbuminemia, edema, and effusions, often mimicking venous or hepatic congestion. Triggers include chronic illness, psychiatric disease, substance use, or restrictive diets. A low serum-ascites albumin gradient (SAAG) supports malnutrition-related third spacing.

Case Presentation

A 29-year-old man with poorly controlled type 1 DM and polysubstance use presented with progressive anasarca, ascites, and pleural effusions. Laboratory evaluation revealed profound hypoalbuminemia (nadir, 1.3 g/dL) and anemia. Diagnostic paracentesis demonstrated low-SAAG ascites (SAAG < 1.1 g/dL) with low ascitic protein (< 2 g/dL), excluding portal hypertension. CTV raised concern for IVC thrombosis, but contrast venography was negative. Prompt exclusion of IVC thrombosis was critical to guide anticoagulation and avoid unnecessary intervention. Alternative etiologies, including nephrotic syndrome, pancreatitis-related ascites, and protein-losing enteropathy, were considered but were less consistent with the overall clinical, laboratory, and imaging findings. Nutritional assessment revealed markedly reduced protein intake and clinical features consistent with severe protein–calorie malnutrition.

Conclusions

Adult kwashiorkor should be considered in unexplained edema and hypoalbuminemia. Low SAAG ascites warrants evaluation for malnutrition. BMI may be misleading due to fluid overload; a full nutritional assessment is essential. Severe hypoalbuminemia likely contributed to venous thromboses.