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Photo Credit – Kerala Kaumudi

Muzaffarpur, Bihar is in focus. 109 deaths of young children within a span of days cannot be ignored by even the most apathetic systems.

There are plenty of discussions, articles, speculations, accusations and counter-accusations…..even as precious lives are being lost. In an attempt to stay focused on the core issue, preventing more deaths of young children, and saving lives, if possible, I contacted Dr. Jacob T John, who had pioneered the research on association of lychees and encephalopathy in 2014. The following are some of the salient points from my conversation with Dr. John.

AES: Acute Encephalitis Syndrome – the phrase is bantered around as the cause of the deaths in Muzaffarpur. It is misleading. AES is a spectrum of diseases. It just means something is causing Acute/ sudden Inflammation of the Brain. The management can only be effective if we can find out what causes the inflammation. It could be infectious, by various bacteria, virus, fungi etc causing meningitis or encephalitis. It could be cerebral malaria. It could be several other causes of inflammation, including metabolic, which itself is a vast spectrum, from chemical causes to heavy metal poisoning. Unless we know the exact cause of the encephalitis, we can’t treat it effectively. Usually pathological examination of the brain fluid (Cerebrospinal fluid-CSF), gives us clues. As far as we know, none of the children in Muzaffarpur have tested positive for a pathogen affecting their brain. This tips the balance in favour of a metabolic cause for the brain fever.

In 2014, Dr.John and team had found strong association between malnourishment, skipping evening meals, consumption of lychees, especially unripe lychees by children in Muzaffarpur, with the outbreak of encephalopathy, which usually manifested with symptoms early in the morning. The common finding was low blood sugar or hypoglycemia. Research has proven that two amino acids (protein building blocks in our body) Hypoglycin A and MCPG (MethyleneCycloPropylGlycine) found in lychees (in much higher concentration in unripe lychees) are also found in high concentration in the urine of the affected children. Link to research: https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30035-9/fulltext

“If you define the problem correctly, you almost have the solution.”

Now, among all the cacophony, let us try to focus on the immediate problem, and find an effective solution, since innocent lives are at stake here.

Lychee alone might not be the problem, malnourishment might be the major contributing factor. But the immediate problem is the amino acids in lychee causing dangerously low blood sugars in malnourished children, leading to brain glucose deprivation, seizures and death. Till we find another absolute causative agent, let us focus on the one we know, and treat the same, especially since the recommended treatment is so simple and inexpensive.

Here is what Dr. John recommends:

  1. Treatment should be started as soon as possible, at least within 4 hours of onset of symptoms.

  2. 10% Dextrose: dose adjusted to bodyweight and age. This 10% strength is important, since we are not just treating hypoglycemia. Here, the alternate path of glucose production, gluconeogenesis, is blocked and this leads to amino acid accummulation (like acyl carnitine) which is highly toxic to brain neurones. Fatty acid oxidation cycle must be shut off quickly for which 10% dextrose is essential — golden period is maximum 4 hours from onset. The glucose given, will increase the blood sugar levels, and this hyperglycemia stimulates insulin which turns the vicious cycle off.

  3. Normal Saline: 3% NaCl is the treatment for brain oedema. Given as a bolus, volume adjusted to body weight. This will increase osmolarity and the cytotoxic brain edema shrinks.

Before more lives are lost, please spread the awareness about the prevention and management of this deadly disease. Meanwhile,simultaneous research into alternate causes, improving long term health concerns like combating malnutrition,(since the toxicity is not seen in well fed children and adults with large body volume, undernourishment should be combated on a war-footing to prevent future cases) and other preventive measures can be implemented. But, what the dying children don’t have is time, what the responsible adults need to do is manage this critical issue in a time-sensitive, emergent manner.

Dr Jessy Skaria is a medical doctor


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