Averting deaths in Muzaffarpur -T Jacob John
All it would have taken was to ensure that the children had a meal at night
Along with my colleagues, I had investigated the so-called mystery disease in Muzaffarpur, Bihar, during its outbreak in 2012, 2013 and 2014. The local name for it was acute encephalitis syndrome, but we found that the disease was not encephalitis but encephalopathy. This distinction is important. Encephalitis results from a viral infection, unless proved otherwise. The pathology is primarily in the brain. Encephalopathy is a biochemical disease, unless proved otherwise. The primary pathology is not in the brain. Specific treatment is scanty for viral encephalitis, but encephalopathy is eminently treatable.
Hypoglycaemia (when the level of glucose in the blood falls below normal) is usually due to an overdose of insulin in children with diabetes. It is easily corrected with oral sugar or intravenous glucose. The easily available 5% glucose solution suffices. Hypoglycaemic encephalopathy, however, is different from simple hypoglycaemia.
The disease pathway
We found that the disease broke out during the months when litchi was harvested, i.e. April, May and June. Muzaffarpur is full of litchi orchards. The illness started suddenly — children were found vomiting, displayed abnormal movements, were semi-conscious, and were convulsing between 4 a.m. and 7 a.m. The disease progressed fast — children went into coma and died within a few days. When sick children were tested, the blood glucose level was always below normal.
This disease was reminiscent of the Jamaican Vomiting Disease, a form of hypoglycaemic encephalopathy. It is triggered when unripe ackee fruits are eaten. These fruits contain a substance, methylene cyclopropyl alanine, which blocks a biochemical process called fatty acid oxidation, or gluconeogenesis.
There are two essential steps: gluconeogenesis is turned on and is then blocked midway by methylene cyclopropyl alanine. The back-up molecules of the unfinished process are certain amino acids that are highly toxic to the brain cells. Ackee and litchi belong to one plant family. My toxicology colleague, Dr. Mukul Das, found generous quantities of methylene cyclopropyl glycine in litchi fruit pulp.
The disease affected only malnourished children between the ages of two and 10. A majority of them were from families camping in orchards for fruit harvesting. No child from the nearby towns fell ill. Children of well-to-do families never fell ill.
Litchi harvest usually begins by 4 a.m., which means that families are awake before that. They go to sleep early. If children go to sleep without dinner, parents usually do not wake them up and feed them. Litchis are collected in bunches and sent to the collection points, but single fruits fall to the ground. Children are free to collect and share the fruits with their friends.
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