Dr KK Aggarwal
In 2015, in a letter to
the Principal Secretary (Health), Government of Bihar, Dr Jagdish
Prasad, the then Director General Health Services had shared the
findings of a study carried out in 2013 on the outbreaks of AES in
Muzaffarpur including the plan and implementation of the study in the year
2014 with an aim to reduce the associated mortality and morbidity. This study
was carried out jointly by NCDC, NVBDCP and ICMR. The US CDC provided technical
support for the study.
Hypoglycemia came up as a
distinctive finding of the study and it was observed that its management
improved prognosis. Hence, it was advised to monitor blood sugar in these
patients. This necessitates availability of glucometer with all Asha workers
and primary health care centers.
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Another
fruit similar to litchi is Ackee fruit (Blighia sapida) a common food source
in West Africa and the Caribbean, especially among impoverished and
malnourished children. The unripe fruit contains high concentration of the
toxin, hypoglycin A, which, when metabolized, inhibits long chain fatty acid
breakdown and transport into the mitochondria. Toxicity manifests as a
Reye-like syndrome with vomiting, hypoglycemia, seizures, and coma occurring
between 2 and 48 hours after ingestion of unripe ackee fruit. Without
rapid correction of hypoglycemia, the death rate approaches 100%. Pathologic
findings on liver biopsy include cholestasis and centrilobular necrosis.
Symptoms of hypoglycemia include neurogenic (autonomic) and neuroglycopenic
symptoms. Severity of symptoms may or may not predict the severity of
the hypoglycemia.
Neuroglycopenic symptoms typically occur at lower plasma glucose levels than
autonomic symptoms. However, with repeated episodes of hypoglycemia, the
threshold glucose concentration for adrenergic symptoms decreases, such that
they may not appear before the onset of neuroglycopenic symptoms
Autonomic symptoms of hypoglycemia in children and adults are due to
increased adrenergic activity, and include sweating, weakness,
tachycardia, tremor, and feelings of nervousness, and/or hunger.
Neuroglycopenic symptoms include lethargy, irritability, confusion,
behavior that is out of character, and hypothermia. In extreme
hypoglycemia, seizure and coma may occur.
In infants, symptoms of hypoglycemia are nonspecific and include jitteriness,
irritability, feeding problems, lethargy, cyanosis, and tachypnea.
When hypoglycemia is suspected, a rapid (bedside) plasma glucose
determination should be performed.
If it is low (≤50 mg/dL for this initial bedside measurement), critical
samples should be obtained before treatment, if this can be done without
delaying treatment. Obtaining critical samples before the initiation of
therapy, and collecting the first voided urine sample, can dramatically
improve the ability to diagnose the etiology of the hypoglycemia and simplify
the subsequent diagnostic evaluation.
These symptoms and signs occur at plasma glucose concentrations between 10
and 50 mg/dL. Severe and repeated episodes of hypoglycemia can result in
permanent central nervous system damage, and occasionally in death.
Treatment of hypoglycemia is IV dextrose; till it is given, 1 tsf sugar with
one drop of water should be given sublingually every 20 minutes.
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The letter further says
that “the morbidity may further be averted if the parents are
sensitized to provide children a good quantity of complex carbohydrate meals
before bed time such as to maintain normal levels of glucose throughout the
night hours.” Malnutrition in the rural low socioeconomic group
children needs to be prevented or reduced.
In the last few days I have
also been talking about starting a 'evening day meal’, to rural children on the
lines of mid-day meal in these months.
Metabolites of certain
compounds (hypoglycin A and methylenecyclopropylglycine or MCPG), which
are naturally present in litchi fruits, were found in the urine of
the patients. These compounds cause hypoglycemia. Children, especially in rural
areas of Muzarffarpur should avoid eating litchi fruits
These cases mostly present in
early morning hours; hence, a trained doctor or a nurse should be posted from
May to July, especially during the night.
The need to strengthen
diagnostic and critical care capacity at all levels of health care was also
emphasized upon to facilitate timely diagnosis and management of such cases.
Following were a few of the
recommendations:
Recommendations to reduce
mortality
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Recommendations
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1.
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Rapid
assessment and correction of hypoglycaemia
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• Through IEC and sensitisation workshops - Increase
awareness among community, field level health workers (ASHAs,
Balwadi/Anganwadi workers, Auxiliary Nurse Midwives, Multipurpose workers,
School health staff etc.) and health staff at PHCs/CHCs/referral treatment
centres on - symptoms of this illness for early detection, - about
availability of free ambulatory services for early transportation, - about
availability of facilities for rapid assessment and correction of glucose at
nearest government health facility as well as - about availability of
specialised treatment facilities at identified referral centres for early
life saving interventions.
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• Provision of adequate numbers of glucometers to all
PHCs/CHCs/referral treatment centres for timely detection of low blood
glucose
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• Train PHCs/CHCs/referral treatment centres staff on
assessment of glucose using glucometer in children presenting with history of
seizures and/or altered sensorium
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• Provide and train staff of PHCs/CHCs/referral treatment
centres on protocol for correction of hypoglycaemia in children with
suspected outbreak illness/ altered sensorium
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2.
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Strengthen
diagnostic and critical care capacity at all levels of health care
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• As characteristically most cases report sickness in
early morning hours, availability of a trained medical doctor during night in
the outbreak season months of May to July at all PHCs/CHCs in the district is
essential for early detection and management of cases.
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• Provide and train staff of PHCs and CHCs on protocol
for first line of life saving health care
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• Strengthen diagnostic facilities at all identified
referral treatment centres for timely and appropriate diagnosis
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Strengthen laboratory facilities for electrolytes,
liver function tests, CSF cytology/biochemistry and bacteriology tests
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Post adequate number trained pathologists/laboratory
technicians for round the clock specimen collection, testing and reporting
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Provide adequate numbers of pulse oximeters
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Provide facilities of EEG and post EEG trained
technicians
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Provide facilities of CT Scans and MRI brain and post
trained Radiologists/Technicians
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Encourage collecting biopsy specimens and
histopathology testing to confirm a tissue diagnosis of encephalopathy
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• Strengthen specialised manpower for assessment and
treatment of cases
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Post adequate number of paediatricians at each of the
identified referral treatment centres to handle increased case load during
outbreak season
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Short term deputation of a neurologist and a critical
care specialist during outbreak season
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Provide treatment guidelines and train paediatricians
of the identified referral treatment centres on this treatment protocol
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Provide training in critical care to paediatricians of
the identified referral treatment centres
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Purpose: Reduce illness
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Recommendations
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3.
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Through
IEC - Increase awareness among community on providing at
night-time a full meal of home-made complex and low glycemic index
carbohydrate (whole intact grains - such as barley (Jav) and oats (Jai); this
would help maintain a stable postprandial blood glucose and possibly minimise
risk of early morning fasting hypoglycemia.
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4.
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Improve
general nutritional status
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Undertake projects to reduce malnutrition among young children, especially
the rural children of low socioeconomic status
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5.
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Considering
the finding of detection of hypoglycin and MCPG (natural hypoglycemic
compounds known to be present in fruits of litchi family) metabolites in
urine specimens of a large proportion of case-patients, it would be advisable
to make efforts by IEC to minimise consumption of litchi fruits among young
children in rural areas of affected district, pending further investigations
in this regards.
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It is difficult to understand
why these recommendations did not get implemented.
Dr KK Aggarwal
Padma Shri
Awardee
President Elect Confederation of
Medical Associations in Asia and Oceania
(CMAAO)
Group
Editor-in-Chief IJCP Publications
President Heart
Care Foundation of India
Past National President
IMA
