Correspondence

Assembly on April 23, 2019,4 can be Although no consensus has 1 Chatterjee P. No cause identified for death of
children in Bihar, India. Lancet 2019;
a vehicle to secure real progress in been reached on the exact cause 393: 2578.
the highest burden countries. As the of the deaths in and around the 2 Slater J. Could the humble litchi fruit be
Commission underscores, effective lychee (Litchi chinensis) plantations behind a mysterious sickness that has killed
nearly 100 children in India? 2019. https://
accountability processes, at national of the Muzzafarpur district of nationalpost.com/news/world/could-the-
and subnational levels, are necessary Bihar, the most accepted cause is humble-litchi-fruit-be-behind-a-mysterious-
sickness-that-has-killed-nearly-100-children-
to ensure a concerted, coordinated hypoglycaemic encephalopathy in-india (accessed June 28, 2019).
response. Efforts like The Lancet (known locally as Chamki fever). 3 Spencer PS, Palmer VS. The enigma of litchi
Tuberculosis Observatory to focus The children (aged 3–7 years) toxicity: an emerging health concern in
southern Asia. Lancet Glob Health 2017;
and sustain expectations on local were from low-income families, 5: e383–84.
political will, through engagement had not eaten the previous evening, 4 Yewale VN. Misery of mystery of Muzaffarpur.
of parliamentarians, civil society, and had eaten unripe lychee in the Indian Pediatr 2014; 51: 605–06.
5 Shrivastava A, Kumar A, Thomas JD, et al.
and local technical experts, will be morning.2 Lychee contains hypoglycin Association of acute toxic encephalopathy
crucial to ensuring the response is A and methylenecyclopropyl glycine with litchi consumption in an outbreak in
courageous and transparent. (a toxic metabolite to mammals), Muzaffarpur, India, 2014: a case-control study.
Lancet Glob Health 2017; 5: e458–66.
We declare no competing interests. which block the alternative pathway
for glucose synthesis (fatty acid
*Michael J A Reid, Eric Goosby
michael.reid2@ucsf.edu
oxidation),3,4 causing a drastic drop
Division of HIV, Infectious Diseases, Global Medicine,
in blood glucose levels and metabolic Parasitic encephalitis in
hypoglycaemia.5
University of California, San Francisco, CA 94158, USA
We urgently need to devise strat-
immunocompetent
1 Reid MJA, Arinaminpathy N, Bloom A, et al.
Building a tuberculosis-free world: the Lancet egies to avoid similar deaths in future. individuals
Commission on tuberculosis. Lancet 2019; Firstly, awareness programmes are
393: 1331–84.
2 Reid MJA, Goosby E. Eradicating TB. BMJ 2018; essential in Bihar, involving public Arun Venkatesan and colleagues 1
362: k3918. broadcasting media, primary schools, adeptly presented the infectious
3 Kruk ME, Yamey G, Angell SY, et al. Anganwadi community health and autoimmune causes of acute
Transforming global health by improving
the science of scale-up. PLoS Biol 2016; workers and government health- encephalitis in immunocompetent
14: e1002360. care centres. These programmes adults. According to the authors,
4 WHO. WHO launches a multisectoral
accountability framework to end TB as
would provide education on under- viruses are the largest group of
requested by the World Health Assembly and nutrition, hypoglycaemia induced acute encephalitis causative agents.
the UN General Assembly. April 23, 2019. by lychee consumption on an The authors also listed bacterial,
World Health Organization. https://www.who.
int/tb/features_archive/multisectoral- empty stomach, and the need for fungal, and parasitic causes of acute
accountability-framework-to-end-TB/en/ immediate intravenous glucose encephalitis. In the parasitic section,
(accessed June 1, 2019).
administration to the sick child if Acanthoemeba species, Naegleria
they show signs of hypoglycaemia. fowleri, Balamuthia mandrillaris, and
Secondly, improvements to hospital Baylisascaris procyonis are listed.
Recurring acute infrastructure and doctor-to-patient However, it seems that some of the
encephalitis syndrome ratios would help to contain major important parasitic causes of acute
See Online for appendix outbreaks. Finally, addressing the encephalitis are missed (appendix).
outbreaks in Bihar, challenge of malnutrition through Toxoplasma gondii is a prevalent
India appropriate implementation of India’s parasite worldwide that can cause
National Food Security Act is crucial. toxoplasmic encephalitis. Although
The death of 154 undernourished Seeking support from international immunocompromised patients are
children from acute encephalitis syn- bodies, such as UNICEF and WHO, more susceptible to acute infection
drome in a short period of 3 weeks1 would be prudent to resolve this long- and toxoplasmic encephalitis, several
is deeply concerning. The World standing problem. cases of encephalitis have been
Report by Patralekha Chatterjee1 is We declare no competing interests. reported in immunocompetent
a timely update on a situation that individuals 2,3 with the symptoms
Shampa Ghosh, Manchala Raghunath,
recurs almost every year in Bihar, *Jitendra Kumar Sinha of encephalitis, dementia, fever,
India. Chatterjee rightly pinpoints jksinha@amity.edu headache, and mild weakness.
undernutrition, inadequate health Toxocariasis is another cause of
National Institute of Nutrition, Hyderabad, India
facilities, and poor awareness among (SG, MR); and Amity Institute of Neuropsychology encephalitis in immunocompetent
the local population as contributing and Neurosciences, Amity University, adults. Toxocara canis and Toxocara
factors to these deaths. Uttar Pradesh 201303, India (JKS) cati are parasites of dogs and cats,

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