From Healthy to Severely Wasted: Marasmic-Kwashiorkor and Suspected Necrotizing Fasciitis of the Lip in a 9-Month-Old Infant

Mercy Maya, Macrina Kato, Zivonishe Mwazyunga, Frank Sifael Kessy, Martin Long’ida Chuva, Gladness Lyimo.

Abstract

Background: Severe Acute Malnutrition (SAM) remains a major cause of infant mortality in low-income countries, often arising from a complex interplay of dietary insufficiency and adverse social determinants of health. Cutaneous complications are common, but severe, rapidly progressive soft tissue infections like necrotizing fasciitis are rare and carry a high mortality risk.
Case Presentation: We report a 9-month-old female infant who presented with a three-month history of progressive weight loss and a one-month history of a non-healing lower lip ulcer. The infant’s weight had plummeted from a healthy 8kg at six months to 4.6kg at admission. Anthropometric measurements confirmed severe wasting and stunting (weight-for-height and weight-for-age < -3SD), with bilateral pitting edema, consistent with marasmic kwashiorkor. The lower lip lesion had evolved from a sore to a pustule and finally to a 2×1.5cm ulcer with regular margins, provisionally diagnosed as suspected necrotizing fasciitis in the context of immunosuppression from SAM. Critically, the etiology was traced to severe dietary insufficiency following the mother’s abandonment by her family after a subsequent pregnancy, leaving her without resources for adequate
complementary feeding. The infant had no history of chronic illness, and HIV serology was negative. The infant initially demonstrated clinical improvement and was discharged home; however, she was readmitted three days later with aspiration pneumonia and sepsis and subsequently died.
Conclusions: This case illustrates the devastating and rapid progression of severe acute malnutrition when compounded by social factors. It highlights the rare but serious complication of necrotizing fasciitis of the lip in an infant with SAM, and tragically demonstrates the high risk of post-discharge relapse and death when underlying social determinants remain unaddressed. The case underscores the need for integrated management that
addresses both severe medical complications and root causes—including family support, food security, robust discharge planning, and communitybased follow-up—to prevent mortality