Encephalitis – Is Litchi The Reason Behind Cham Ki Bukhar In Bihar?

Recently, in Bihar, India, over 100 children died due to Acute Encephalitis Syndrome (AES). Most of these cases were due to hypoglycemia or low blood sugar levels. Doctors believe that this was due to eating litchi without proper nourishment. A toxin in litchi, MCPG, inhibits glucose formation in the morning. This is an essential pathway for malnourished children to compensate for low blood sugar levels in the morning as they do not have emergency glucose reserve in the liver. 

Thus, eating a lot of litchi at night and sleeping on an empty stomach resulted in hypoglycemia in malnourished children. They further experienced brain dysfunction and feverish symptoms.

Poor brain function can lead to drowsiness, disorientation, and even unconsciousness. Furthermore, hampered biochemical processes result in toxic amino acids that cause brain cells to swell. As a result, children may suffer from convulsions, deepening coma and even death.

Hypoglycemic encephalopathy, the condition that the malnourished children in Bihar faced is distinct from encephalitis. In the case of encephalitis, there is brain inflammation due to a viral infection. In contrast, hypoglycemic encephalopathy is caused due to a biochemical reaction that leads to brain dysfunction. Thus, while flu-like symptoms occur in encephalitis patients even before brain inflammation, encephalopathy patients suffer from flu symptoms after brain dysfunction. The most important difference is in the WBC count per unit volume. There is a marked increase in the case of encephalitis due to brain inflammation. This does not happen in the case of hypoglycaemic encephalopathy.

Are healthy, well-nourished children at the risk of AES if they eat litchis?

Healthy children can eat litchis without any fear. They have sufficient glucose reserve in their liver. Thus, when they experience low blood sugar levels in the morning, they have a reserve that manages the deficit. Their bodies do not have to resort to another pathway to create glucose, which is blocked by the toxin in litchi.

At a Glance:

What is encephalitis?

Encephalitis is an inflammation of the brain, generally caused due to a viral infection. Also commonly known as ‘brain fever’ or ‘chamki bukhar’, it is characterised by flu-like symptoms such as headache, dizziness, and joint pain. It can often be difficult to diagnose due to the commonality of its signs and symptoms with other diseases like flu, meningitis, etc.

The risk due to the condition varies based on a number of factors. Each case also manifests itself differently based on the affected person’s unique situation. Therefore, quick diagnosis and treatment are essential in treating encephalitis efficiently. With the appropriate treatment, a person with a mild infection can recover completely.

What are the signs and symptoms of encephalitis in infants & children?

The signs and symptoms of encephalitis are similar for everyone. They experience flu-like signs and symptoms, which may progressively worsen and continue for a period of time. These are:

• Fever
• Headache
• Dizziness
• Poor appetite
• Photophobia – sensitivity to light

There are some other less common signs and symptoms of encephalitis that a person may experience, including:

• Nuchal rigidity (neck stiffness)
• Stiffness of the limbs, slow movements, and clumsiness
• Cough

Sometimes the signs and symptoms can be more severe and can be a cause for concern. They can make the patient aggressive since they experience:

• Severe headaches
• Nausea and vomiting
• Confusion and disorientation
• Hallucinations
• Loss of consciousness
• Memory loss
• Speech and hearing problems
• Seizures
• Coma

It might be harder to detect the signs and symptoms of encephalitis in infants. These are some signals to look out for:

• Nausea and vomiting
• Bulging fontanel (soft spot on a baby’s skull)
• Body stiffness
• Continuous crying even when picked up and comforted.

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What are the different types of encephalitis?

It can be classified into two types based on how it occurs:

• Primary encephalitis: This refers to direct infection of the brain or spinal cord by fungus, virus, or bacterium. It can be confined to a particular area or be more widespread.
• Secondary encephalitis: The infection, in this case, spreads to the brain from some other infected area. The immune system mistakenly attacks the brain while responding to the other infection and causes inflammation. The incubation period is longer (about 2-3 weeks) as it does not affect the brain directly.

What are the causes of encephalitis?

Encephalitis is an extremely unpredictable disease, and its causes are often hard to pinpoint. The exact cause of illness cannot be found out in more than 50% of encephalitis cases. It can generally be attributed to viral infections.

Most cases of encephalitis fall under primary encephalitis, which is also infections. They are caused due to three reasons:

• Viruses like herpes simplex virus (HSV) commonly cause encephalitis.
• There are rarer cases of childhood infections like measles and mumps causing the disease.
• Arboviruses, which are spread by mosquitoes and ticks, are common causes of encephalitis. Japanese encephalitis falls under this category.

Secondary encephalitis is a rarer condition. Research is still being done to figure out its exact cause since the brain is affected indirectly in this case. It is possible that a complication in the viral infection leads to secondary encephalitis. Its signs and symptoms begin to appear only after the initial infection is underway, maybe after days or weeks. The patient’s immune system responds to the disease and starts attacking the brain cells in the process.

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Can litchi cause encephalitis in children?

No, eating litchi does not cause encephalitis in children. Recently, in India, acute encephalitis syndrome (AES) led to the deaths of more than 100 children. These deaths were caused due to hypoglycemia or low blood sugar levels that were triggered and aggravated by the consumption of litchi and sleeping in empty stomach. Litchi contains the toxin methylene cyclopropyl glycine (MCPG), which blocks the production of glucose by the liver. Therefore, its consumption on an empty stomach by malnourished children leads to fatal hypoglycemia. Litchi by itself does not cause encephalitis or death.

In encephalitis, the child is already low on glucose and depends on the emergency reserve which is further limited due to the consumption of litchi. Inadequate glucose in the brain impairs function and causes drowsiness, disorientation and even unconsciousness. Furthermore, hampered biochemical processes result in toxic amino acids that cause brain cells to swell. As a result, children may suffer from convulsions, deepening coma and even death.

Therefore, healthy children can eat litchis without any fear. To prevent hypoglycaemic encephalopathy in malnourished children:

• One must ensure that they eat a limited amount of litchi.
• Make sure that they don’t sleep at night on an empty stomach.

Are encephalitis and hypoglycemic encephalopathy different?

Yes, hypogylcaemic encephalopathy is distinct from encephalitis, wherein the fever occurs even before the onset of brain inflammation. Other flu-like symptoms such as vomiting and drowsiness also occur after the brain is affected.

Hypoglycaemic encephalopathy

• Caused due to a biochemical reaction.
• Brain dysfunction occurs.
• Flu-like symptoms AFTER brain dysfunction.
• No increase in WBCs per unit volume (as no brain inflammation).

Encephalitis

• Caused due to a viral infection.
• Brain inflammation occurs.
• Flu-like symptoms BEFORE brain inflammation.
• There is an increase in WBCs per unit volume (due to the brain inflammation).

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Is encephalitis contagious?

Whether encephalitis is contagious or not depends on its underlying cause. For example,

• Arboviruses i.e. viruses transmitted through the bite of infected insects are not considered to be contagious. While brain inflammation cannot be transmitted person to person, the virus itself can be contagious. Catching the virus does not necessarily lead to encephalitis.
• Encephalitis can be contagious in the case of some herpes viruses. They can be transmitted between people.
• Secondary encephalitis is not contagious as it results from autoimmune dysfunction.

The contagious period for encephalitis depends on its cause as well. The attacking virus and the disease vary to a great degree. Since encephalitis occurs differently in each patient, it is best to consult a specialist for more information.

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What are the risk factors of encephalitis?

Encephalitis is rarely life-threatening. Provided that the infection is moderate in nature, patients can recover with the appropriate treatment. Mortality depends on the following factors:

• Age: Children and older people are at higher risk of suffering from encephalitis. The condition is also more severe for them.
• Weak immune system: Certain groups of people like those suffering from HIV/AIDS or having a weak immune system due to regular intake of immuno-suppressants having greater chances of encephalitis.
• Geographical regions: Arboviral viruses can be spread very easily in regions where mosquitoes and ticks are present in large numbers, causing encephalitis.
• Seasonal changes: During the summer and monsoon, ticks and mosquitoes are more likely to spread viruses that cause encephalitis.

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Who is more prone to encephalitis?

As discussed above, certain conditions are more likely to lead to encephalitis. They can also cause an increase in its severity.

• Children and older people are more likely to be affected by encephalitis.
• People with a weak immune system due to HIV/AIDS or other causes stand at a higher risk of encephalitis.
• People who live in areas with mosquitoes and ticks can be exposed easily to encephalitis.

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How is encephalitis diagnosed by doctors?

Doctors need to know the patient’s history, medical and otherwise, before diagnosing encephalitis. They will often check symptoms, ask about the patient’s travel history, his/her geographic location, etc. This can help them to both identify the disease and its specific cause. Further diagnostic tests will need to be done to confirm encephalitis.

The following tests can be done based on the patient’s unique situation:

1. Neurological examination: This will be done if the patient feels drowsy.
2. Diagnosis test for meningitis or meningoencephalitis: This can be done if the patient experiences stiffness in the neck. It will rule out the possibility of neck meningitis.
3. Polymerase chain reaction (PCR) test: It detects the genetic material of the virus. It can be used to identify the types of virus that cause encephalitis.
4. Lumbar puncture: A sample of cerebrospinal fluid from the spine is taken. It is useful in detecting if the levels of protein and white blood cells are higher than normal. Unfortunately, it is not always conclusive.
5. CT scan: It can reveal the changes in the structure of the brain. This helps in ruling out other causes for the symptoms like stroke, aneurysm, and tumor.
6. MRI: It helps to identify typical changes that are associated with encephalitis. It is, therefore, the best imaging option.
7. EEG (electroencephalograph): The presence of sharp waves in one or both lobes indicates that the patient is affected with encephalitis.
8. Blood test: It helps to confirm the presence of a West Nile viral infection.
9. Urine or serum toxicology: In case the patient experiences confusion or delirium.
10. Brian biopsy: It is a rare diagnostic test and done only if other tests are inconclusive.

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Which specialists treat encephalitis?

Since encephalitis has many causes, the treatment for it differs as well. The type of specialists who may be consulted for encephalitis depends on the underlying cause of the disease. Therefore, the people who are consulted can include:

• Pediatricians
• Emergency-medicine specialists
• Toxicologists
• Oncologists
• Neurologists

Depending on the case, other specialists can be consulted to diagnose and treat the disease.

What is the medical treatment for encephalitis?

There are a few complications that arise in the treatment of encephalitis.

• Encephalitis is generally caused by a viral infection. So antibiotics cannot be given to treat it.
• HSV infections can be treated with the use of antiviral drugs. However, no drugs to date can treat arboviral infections.
• If encephalitis is caused due to non-viral reasons, the treatment has to change accordingly.

The following procedures are followed in the case of a few variants of encephalitis:

• Antiviral drugs can be given through IV for two to four weeks if the condition is caused by Herpes Simplex Virus (HSV).
• Alleviation of symptoms is the primary mode of treatment if encephalitis is not caused by HSV. This can include hydration with IV fluids and using paracetamol to treat headaches. It is important to monitor brain swelling during hydration. Diuretics may be needed if the patient has increased intracranial pressure.
• Corticosteroids can be used to reduce inflammation of the brain, especially if it is secondary encephalitis.
• Mechanical ventilation may be required if the patient had severe signs and symptoms and requires support in order to breathe.
• Anticonvulsants are given to patients with seizures.
• Sedatives can be used for patients with seizures, restlessness, and irritability.

What are the complications in encephalitis?

Complications can arise in encephalitis, especially if the condition is severe. Older patients with a weaker immune system and children are at higher risk of such complications. Patients who do not begin treatment in the early stages of encephalitis may also suffer from side effects.

The complications are:

• Aphasia i.e. language and speech problems
• Memory loss
• Epilepsy
• Behavioral or personality changes

How long does encephalitis last?

The acute phase of encephalitis, with the worst of the symptoms, can last up to a week. Full recovery from encephalitis can take much longer. Most patients take several weeks or even months to recover completely.

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Is it possible to prevent encephalitis?

There are several precautions which can be taken to prevent encephalitis. These include:

• Vaccines: It is essential to keep up-to-date with all the vaccines, whether age-specific or region-specific. Vaccinations before travelling can also help in reducing the risk of developing encephalitis.
• Good hygiene: The best of preventing viral infections is by maintaining cleanliness. Practices such as washing hands help a lot.
• A Caesarian section: In case the mother has active herpes lesions of the genital tract, a c-section protects the baby from it.
• Prevention of mosquito and tick bites: Mosquitoes can carry encephalitis-causing viruses, therefore, mosquito bites can be prevented by using repellant, wearing appropriate clothing, avoiding areas with stagnant water, etc. Similar measures can be taken for ticks.

What is the prognosis or outcome of encephalitis treatment?

The outcome of encephalitis for patients depends on a variety of factors. As discussed before, the condition manifests itself differently for each patient. Severity depends on the age and the person’s immune system. However, most patients recover completely from mild encephalitis and face no lasting complications.

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Read more about Encephalitis symptoms, causes and treatment

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References:

• https://www.medicalnewstoday.com/articles/168997.php
• https://www.emedicinehealth.com/encephalitis/article_em.htm#follow-up_for_encephalitis
• https://kidshealth.org/en/parents/encephalitis.html
• https://www.mayoclinic.org/diseases-conditions/encephalitis/symptoms-causes/syc-20356136
• https://www.nhs.uk/conditions/encephalitis/
• https://www.thehindu.com/sci-tech/health/explainer-how-is-litchi-toxin-causing-deaths-in-undernourished-children-in-muzaffarpur/article28075727.ece