Methylenecyclopropyl glycine, not pesticide exposure as the primary etiological factor underlying hypoglycemic encephalopathy in Muzaffarpur, India.

Some districts of Bihar, especially Muzzaffarpur district, have been known to be affected by annual outbreak, called locally as Acute Encephalitis Syndrome (AES) which became one of the major health concerns in Bihar, due to its high fatality and complications. Several hypotheses like bat virus, heat stroke, pesticide exposure and the presence of a compound - methylenecyclopropyl glycine (MCPG) in Litchi have been proposed by different investigators for AES. When the investigators examined the symptoms, signs and the epidemiological data, bat virus and heat stroke hypothesis were ruled out. Two major hypotheses which remain in question were the exposure to pesticides or MCPG present in litchi. Therefore, this study was designed to check the presence of both in the Muzzaffarpur samples of ripe and semi ripe litchi fruits. The fruit cover of ripe and semi ripe litchi showed the traces of Malathion (0.18-0.19 µg/g) and p'-p'-DDT (0.022-0.023 µg/g), while no pesticide residues were detected in the pulp of ripe or semi ripe litchi thereby ruling out the possibility of pesticide exposure in children of Muzzaffarpur. However, MCPG was detected in the pulp of semi ripe (0.57 µg/g) and ripe litchi fruits (0.19 µg/g). Further, when the human condition was simulated in animals, there was deprivation in body weight and glucose levels in starved litchi seed dosed rats, causing hypoglycemia. These results suggest that the cause of hypoglycemic encephalopathy in Muzzaffarpur is related to the consumption of semi ripe and ripe litchi fruits by undernourished children.

A Previously Healthy Adolescent With Acute Encephalopathy and Decorticate Posturing.

A 14-year-old previously healthy female was transferred from a local emergency department after being found unresponsive at home. Parental questioning revealed she had fever and pharyngitis 2 weeks before presentation. Past mental health history was negative, including concern for past or present suicidal ideation/attempts, suspected substance use, or toxic ingestion. In the emergency department, she was orotracheally intubated due to a Glasgow Coma Scale of 3. She was hemodynamically stable and euglycemic. Electrocardiogram showed sinus tachycardia. She underwent a noncontrast head computed tomography that was normal and subsequently underwent a lumbar puncture. She had a seizure and was given a loading dose of diazepam and fosphenytoin that led to cessation of extremity movements. She was subsequently transferred to the PICU for additional evaluation. Initial examination without sedation or analgesia demonstrated dilated and minimally responsive pupils, intermittent decorticate posturing, and bilateral lower extremity rigidity and clonus, consistent with a Glasgow Coma Scale of 5. Serum studies were unremarkable with the exception of mild leukocytosis. Chest radiograph only showed atelectasis. She was empirically started on antibiotics to cover for meningitis pending final cerebral spinal fluid test results. The pediatric neurology team was consulted for EEG monitoring, and the patient was eventually sent for computed tomography angiogram and magnetic resonance angiogram/venogram. We will review diagnostic evaluation and management of an adolescent patient with acute encephalopathy with decorticate posturing of unclear etiology.