Children in Muzaffarpur frequently spend the day eating litchis and some skip the evening meal. Skipping evening meal, by itself results in low blood sugar levels during the night. This is particularly so in the case of young children as they have limited hepatic glycogen reserves. Hypoglycin A and methylene cyclo propyl glycine (MCPG), which are naturally present in litchi fruit, make the condition worse. The toxins block enzymes involved in normal glucose metabolism and this results in an inability to synthesise glucose leading to acutely low level of blood sugar. The build-up of other metabolic by-products could also have an adverse effect (encephalopathy) on the child. These two cause death in many children. The study shows the modifying effect of skipping the evening meal on the impact of these toxins.

In 2013, scientists from Delhi’s National Centre for Disease Control, India (NCDC) and the U.S. Centres for Disease Control and Prevention (CDC) started an investigation. The first focus of the team was to evaluate if the mysterious condition was due to an infectious cause or not. “Most of the children did not have fever. And on testing the spinal fluid we did not find elevated white blood cell count. These two indicated that it was less likely to be to an infectious cause. It gave us a clue that we should look at non-infectious causes,” recalls Dr. Padmini Srikantiah, Global Disease Detection Programme-India, CDC, Atlanta and the corresponding author of the paper.

With infectious causes ruled out and most sick children presenting with low blood glucose levels the team started investigating the role of toxins — exposure to pesticide, insecticide and heavy metals to name a few.
Over 62% sick children had blood glucose level less than 70 mg/dL. The median was 48 mg/dL and it was as low as 8 mg/dL.

Researchers compared 104 children with illness with similar number of controls. They found metabolites of hypoglycin A and MCPG in 66% (48 of 73 cases) of urine samples but none from the 15 controls. About 90% of children with illness showed severe disruption of fatty acid metabolism. In 36 litchi samples tested, hypoglycin A ranged from 12.4-152 micrograms per gram and MCPG ranged from 45-220 micrograms per gram. The level of hypoglycin A and MCPG was twice in unripe compared with ripe fruits.

Courtesy: Lancet Global Health

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