Brain disease plaguing Muzaffarpur children is not encephalitis

The recurrent outbreak of brain disease among children in Muzaffarpur, Bihar, during the months of April, May and June every year is categorically hypoglycaemic encephalopathy and not encephalitis.  

I don’t know what’s happening there this time but I can say that our research during the outbreak in 2012, 2013 and 2014, revealed encephalopathy — a biochemical disease. Encephalitis, on the other hand, results from a viral infection.

Acute encephalitis syndrome (AES) is a broad term and viral encephalitis is a part of it, which spills over before April and after July. The disease may include hypoglycaemic encephalopathy but it will lose the specificity of a diagnosis. Besides, AES also includes bacterial meningitis. So, the word AES is actually both useless and harmful.

The National Centre for Disease Control (CDC) made a mistake calling it AES. That should have never been used in clinical practice, in which diagnosis and treatment are specific to diseases, not lookalikes. So, I think, that is where things are going wrong. 

AES has so far claimed lives of 133 children in Muzaffarpur alone and more than 150 in the whole of Bihar, according to media reports.

During my time in Muzaffarpur, people were very receptive. We told people to ensure that children take proper meals at night. The doctors also understood the logic behind the diagnosis and treatment and they followed it up very diligently.

In a session for primary health centre (PHC) doctors (involving 32 doctors), they were taught that in the case of encephalitis, children fall sick between 4 am and 7 am in the morning. Since, no virus keeps a watch at this hour, it is just a cycle of the body.

AES is usually manufactured during the hot part of the day. So, if AES begins in the afternoon at 2 o'clock it is unlikely to be hypoglycaemic encephalopathy. This distinction is critical.

If a child had fever for two or three days prior to the brain disease, then it can be the infection encephalitis.

On the other hand, hypoglycaemic encephalopathy happens when a child goes to bed without any problem, but develops brain symptoms early in the morning and then fever, it is encephalopathy. 

The symptoms include vomiting followed by drowsiness, abnormal muscle movement early in the morning. This is not a disease caused by heat and it is not a viral infection. 

Moreover, AES affects adults more than children, while hypoglycaemic encephalopathy affects only children.

Encephalopathy is a medical emergency. It raises the risk of death, if not treated quickly. With encephalitis, there is no specific treatment as well as no immediate risk of death.

The deaths recently seen in Bihar are a combination of three factors:

1) Undernutrition 

2) Prolonged fasting

3) Litchi — which contains a substance methylene cyclopropyl alanine. This substance blocks a biochemical process called fatty acid oxidation, or gluconeogenesis. 

If these three factors do not come together, no child will develop the disease or die of the disease. I first came up with the diagnosis in 2012 and later confirmed in 2013. Further, in 2015, all missing links were established. 

Diagnoses is key

It is purely a biomedical issue and should be sorted out by doctors with a few tests; one is blood sugar.

If the blood sugar is 150 milligrams per decilitre (mg/dl), then it cannot be hypoglycaemic encephalopathy; it has to be below 70 mg/dl.

Another is a lumbar puncture and chronic fatigue syndrome (CFS) cell count test.

I found that no lumbar puncture test was done among children diagnosed with AES in Muzaffarpur.  

Both are entirely different diseases. In encephalitis, the brain is affected and ‘itis’ shows it’s a brain inflammation. ‘Itis’ is used whenever there is an inflammatory disease like meningitis, conjunctivitis and that immediately attacks white blood cells.

In a lumbar puncture test, also known as a spinal tap, the CSF will show an increase in number of white blood cells.

Encephalopathy has no inflammation. It has brain edema. There will be no increase in white blood cells either in the brain or in the cerebro spinal fluids.

We may ask why lumbar puncture test was not done in Bihar. The test requires more human resource. You must have enough hands to do this.

If you suddenly send 50 children to a medical college, how can they handle. When there is a fire, the fire agency comes in. Here when there is a fire, the same people who are looking after the general ward have to double up and do that also. The medical college is not made for this outbreak. 

Do not thrust these extra cases to them. A PHC is more than enough to handle these cases. ‘Do not send children from PHCs to medical college hospital’ was one of the instructions we had given.

A blood sugar test can be done at a PHC; glucose machines have been supplied to every PHC. 

(T Jacob John, retired professor of virology from Christian Medical College (CMC), Vellore, along with Muzaffarpur-based pediatrician Arun Shah, had investigated the outbreak in 2012, 2013, and 2014.) 

As told to Shagun Kapil

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