Protein Energy Malnutrition (PEM) describes spectrum of clinical conditions with varying feature and biochemical findings. At one end is Marasmus (protein-calorie malnutrition), a syndrome related chronic dietary restriction of energy, protein and other nutrients. Marasmus is associated with diseases such as anorexia nervosa, GI cancer, chronic illness, and old age. Marasmic patients often appricachectic as a result of a slow, progressive loss from adipose and muscle tissue. at the other end, Kwashiokor (protein malnutrition) develops as a result of a prolonged deficit dietary protein intake accompanied by adequate energy intake. Dietary intake is primarily in the form of carbohydrates. Kwashiokor is associated with fad diets, partial obstruction of the upper GI tract, and prolonged use of protein free dextrose intravenous solutions. Patient presenting with protein malnutrition may not appear malnourished and may actually be obese. Kwashiokor may be overlooked unless a careful assessment of laboratory data is made.