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New Delhi, June 20, 2019 :
Dr K K Aggarwal
1. Lychee fruit ( especially unripe) consumption followed by fasting
2. Lychee fruit consumption after overnight fasting in the morning
3. Doing only Lychee fast
In malnourished children is associated with outbreaks of hypoglycemia and encephalopathy with high mortality (10% deaths is seen in severe hypoglycemia).
Metabolites of hypoglycin A and methylene-cyclo-propyl-glycine MCPG are found in two-thirds of urine specimens from the victims.
Another similar fruit is Ackee fruit (Blighia sapida) a common food source in West Africa and the Caribbean, especially among impoverished and malnourished children.
Edible when ripe and properly prepared, 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 percent.
Pathologic findings on liver biopsy include cholestasis and centrilobular necrosis.
Symptoms of hypoglycemia
Neurogenic (autonomic) symptoms
Neuroglycopenic symptoms.
The 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 : IV dextrose
Till it is given give one TSF sugar with one drop of water sublingual every twenty minutes healthysoch
MOH Findings
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 Muzarffarpur 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 its management improved prognosis. It necessitates availability of glucometer with all Asha workers and primary health care centers.
Hence, it was advised to monitor blood sugar in these patients. 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 ‘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. This would facilitate timely diagnosis and management of such cases.
Public Health Answer: Regulate Lychee production and Consumption so that rotten unripe Lychee is not consumed by children.
