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Lychee Linked Encephalitis

The toxic substance in lychee causes Acute Encephalitis Syndrome (AES), locally known as Chamki Bukhar, which is a form of brain fever that happens due to the inflammation of the brain. The symptoms of AES include fever, vomiting and unconsciousness or onset of seizures. This condition affects only young children, mostly under 10 years of age.

A Lancet report established a link between the consumption of unripened lychees (containing hypoglycin A or Methylene cyclopropyl-glycine (MCPG) resulting in hypoglycaemia and death from acute toxic encephalopathy.
Hypoglycin A is a water-soluble liver toxin, that upon ingestion leads to hypoglycemia through the inhibition of gluconeogenesis… resulting in hypoglycaemia and death from acute toxic encephalopathy especially in malnourished children.

Outbreaks of AES have occurred every year in Muzaffarpur (Bihar) and neighbouring districts since 1995 and is at risk when the fruit is harvested commercially in May and June.

Treatment

Establish an IV line. Look for the sign and symptoms of shock  Capillary refill > 3 secs (pediatric patient)  Cold extremities  Weak and rapid pulse Assess pediatric patient for dehydration No dehydration  Symptomatic management  Look for signs of referral  2/3 rd of maintenance fluid by Intravenous route. Grade dehydration as some/ severe dehydration  Severe dehydration: IV fluid Ringer lactate/ Normal Saline as per WHO guidelines  Some dehydration IV fluid ñ Ringer Lactate/ Normal saline   Shock present IV fluid Ringer Lactate 20 ml/kg/ hr Reassess (Repeat if shock Persists) Ringer Lactate ñ 20 ml/kg, if shock improves, the child is euvolemic, give maintenance fluid, Shock Persists ñ Inotrope Dopamine drip in maintenance fluid 5 mcg/kg/ minute then again increase Dopamine up to 20mcg/kg/minute and similarly Dobutamine start with 5mcg/kg/minute & increase up to 20 mcg/kg/minute (Till BP stabilizes) Improvement: Continue maintenance IV fluid No improvement: Refer to higher centre NB: These are broad guidelines; ultimate decision regarding management will depend upon the attending physician.

MANAGEMENT OF CONVULSIONS & I.C.T.

Give anticonvulsants if there was a history of convulsions and not given earlier, or convulsions are present.

1. Phenobarbitone (Gardinal/Luminal) 20-40mg/kg As loading dose 200mg per ml. ampule I/V Slowly after dilution in normal saline Convulsion in infants can be used in all age groups Good drug controlling seizure & long term use.

2. Phenytoin (Eptoin/Dilantin) 15-20mg/kg 100mg/ 2ml amp. I/V Slowly after dilution in normal saline Convulsion in all age all groups Good drug for the control of seizure & as maintenance

3. Sod. Valproate 20-40 mg/kg I/V Oral Syrup Syrup can be given as per rectal to all age group.

4. Diazepam 0.1-0.3mg/kg I/V or P/R  I/V slowly  Syrup Suppository P\R Uncontrolled Convulsions May cause respiratory arrest in newborns & infants.

5. Lorazepam 0.05-0.1mg/kg oral, I\V I/V Slowly Uncontrolled Convulsion Safe in infants Tachycardia, depression Confusion blurred vision

6. Midazolam 0.2mg/kg 1mg/5kg S/C, intranasal safe in injections Uncontrolled convulsion in infants Short-acting

7. Inj. Paraldehyde 11% 0.1-0.2mcg/kg deep gluteal can be replaced after ½-hrs. Maintenance Dose – Phenobarbitone 3-8mg/kg/day I/V or oral – Phenytoin 5-8 mg/kg/day I/V or oral – Sodium Valproate 40-60mg/kg/day Oral

MANAGEMENT OF INCREASED INTRACRANIAL PRESSURE(Tension)

(Only after correction of Dehydration)

1. Mannitol 20% I/V ñ 5 ml/kg in ½ hrs as 1 st dose than 2.5 ml/kg at 6 hrs. intervals up to 48 hours (8 doses).

2. Injection Lasix I/V ñ 1 mg /kg up to 40 mg can be given.

3. Glycerol solution:- Oral ñ 0.5 ml/kg mix with fruit juice can be given by nasogastric tube ñ 3 times a day.

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