Determinants of cognitive performance in children relying on cyanogenic cassava as staple food.

While risk factors for konzo are known, determinants of cognitive impairment in konzo-affected children remain unknown. We anchored cognitive performance (KABC-II scores) to serum levels of free-thyroxine (free-T4), thyroid-stimulating hormone (TSH), albumin, and motor proficiency (BOT-2 scores) in 40 children including 21 with konzo (median age: 9 years) and 19 without konzo (median age: 8 years). A multiple regression model was used to determine variables associated with changes in KABC-II scores. Age (ß: -0.818, 95% CI: -1.48, -0.152) (p = 0.018), gender (ß: -5.72; 95% CI: -9.87, -1.57 for females) (p = 0.009), BOT-2 score (ß: 0.390; 95% CI: 0.113, 0.667) (p = 0.008), and free-T4 (ß: 1.88; 95% CI: 0.009, 3.74) (p = 0.049) explained 61.1 % of variation in KABC-II scores. Subclinical hypothyroidism was not associated with poor cognition. A crude association was found between serum albumin and KABC-II scores (ß: 1.26; 95 % CI: 0.136, 2.39) (p = 0.029). On spot urinary thiocyanate reached 688 µmol/l in children without konzo and 1,032 µmol/L in those with konzo. Female gender and low serum albumin are risk factors common to cognitive and proportionally associated motor deficits in children exposed to cassava cyanogens. The two types of deficits may share common mechanisms.

Motor control and cognition deficits associated with protein carbamoylation in food (cassava) cyanogenic poisoning: Neurodegeneration and genomic perspectives.

A case-control design determined whether konzo, an upper motoneuron disease linked to food (cassava) toxicity was associated with protein carbamoylation and genetic variations. Exon sequences of thiosulfate sulfurtransferase (TST) or mercaptopyruvate sulfurtransferase (MPST), plasma cyanide detoxification rates, and 2D-LC-MS/MS albumin carbamoylation were assessed in 40 children [21 konzo-affected and 19 putatively healthy controls, mean (SD) age: 9.2 (3.0) years] subjected to cognition and motor testing using the Kaufman Assessment Battery and the Bruininks/Oseretsky Test, respectively. Konzo was significantly associated with higher levels of carbamoylated peptides 206-219 (LDELRDEGKASSAK, pep1) after adjusting for age, gender, albumin concentrations and BUN [regression coefficient: 0.03 (95%CI:0.02-0.05), p = 0.01]. Levels of pep1 negatively correlated with performance scores at all modalities of motor proficiency (r = 0.38 to 0.61; all p < 0.01) or sequential processing (memory)(r = - 0.59, p = 0.00) and overall cognitive performance (r = - 0.48, p = 0.00) but positively with time needed for cyanide detoxification in plasma (r = 0.33, p = 0.04). Rare potentially damaging TST p.Arg206Cys (rs61742280) and MPST p.His317Tyr (rs1038542246) heterozygous variants were identified but with no impact on subject phenotypes. Protein carbamoylation appears to be a reliable marker for cassava related neurodegeneration.

Lower sulfurtransferase detoxification rates of cyanide in konzo-A tropical spastic paralysis linked to cassava cyanogenic poisoning.

Using a matched case-control design, we sought to determine whether the odds of konzo, a distinct spastic paraparesis associated with food (cassava) cyanogenic exposure in the tropics, were associated with lower cyanide detoxification rates (CDR) and malnutrition. Children with konzo (N=122, 5-17 years of age) were age- and sex-matched with presumably healthy controls (N=87) and assessed for motor and cognition performances, cyanogenic exposure, nutritional status, and cyanide detoxification rates (CDR). Cyanogenic exposure was ascertained by thiocyanate (SCN) concentrations in plasma (P-SCN) and urine (U-SCN). Children with a height-for-age z-score (HAZNCHS)<-2 were classified as nutritionally stunted. CDR was measured as time required to convert cyanide to SCN, and expressed as ms/µmol SCN/mg protein or as mmolSCN/ml plasma/min. Mean (SD) U-SCN in children with konzo was 521.9 (353.6) µmol/l and was, significantly higher than 384.6 (223.7) µmol/l in those without konzo. Conditional regression analysis of data for age- and sex- matched case-control pairs showed that konzo was associated with stunting (OR: 5.8; 95% CI: 2.7-12.8; p<0.01; N=83 paired groups) and higher U-SCN (OR: 1.1; 95% CI: 1.02-1.20 per 50-µmol increase in U-SCN; p=0.02; N=47 paired groups). After adjusting for stunting and U-SCN, the odds of developing konzo was reduced by 63% (95% CI: 11-85%, p=0.03; N=41 paired groups) for each 5mmol SCN/(ml plasma/min)-increase in CDR. Linear regression analysis indicated a significant association between BOT-2 or KABC-II scores and both the HAZNCHS z-score and the U-SCN concentration, but not the CDR. Our findings provide evidence in support of interventions to remove cyanogenic compounds from cassava prior to human consumption or, peharps, enhance the detoxification of cyanide in those relying on the cassava as the main source of food.

Konzo prevention in six villages in the DRC and the dependence of konzo prevalence on cyanide intake and malnutrition.

Six villages in Boko Health Zone, Bandundu Province, DRC, were studied with 4588 people, 144 konzo cases and konzo prevalences of 2.0-5.2%. Konzo incidence is increasing rapidly in this area. Food consumption scores were obtained from the households with konzo and the mean % malnutrition calculated for each village. Urine samples were obtained from 50 school children from each village and % high urinary thiocyanate content (>350 µmol/L) determined. The experimental data relating % konzo prevalence (%K) to % children with high urinary thiocyanate content (%T) and % malnutrition (%M) for the six villages were fitted to an equation %K = 0.06%T + 0.035%M. This confirms that konzo is due to a combination of high cyanide intake and malnutrition. The village women used the wetting method to remove cyanogens from cassava flour. During the 9-month intervention there were no new cases of konzo; cyanide in flour had reduced to WHO safe levels and mean urinary thiocyanate levels were greatly reduced. To prevent konzo at least 60-70% of women should use the wetting method regularly. The wetting method is now accepted by the World Bank, FAO and WHO as a sensitive intervention. Four successful konzo interventions have involved nearly 10,000 people in 13 villages, the cost is now $16 per person and the methodology is well established.

Lower serum levels of selenium, copper, and zinc are related to neuromotor impairments in children with konzo.

We assessed the relationship between key trace elements and neurocognitive and motor impairments observed in konzo, a motor neuron disease associated with cassava cyanogenic exposure in nutritionally challenged African children. Serum concentrations of iron, copper, zinc, selenium, and neurotoxic lead, mercury, manganese, cadmium, and cobalt were measured in 123 konzo children (mean age 8.53 years) and 87 non-konzo children (mean age 9.07 years) using inductively coupled plasma mass spectrometry (ICPMS). Concentrations of trace elements were compared and related to performance scores on the Kaufman Assessment Battery for Children, 2nd edition (KABC-II) for cognition and Bruininks-Oseretsky Test, 2nd edition (BOT-2) for motor proficiency. Children with konzo had low levels of selenium, copper, and zinc relative to controls. Selenium concentration significantly correlated with serum 8,12-iso-iPF2α-VI isoprostane (Spearman r=0.75, p<0.01) and BOT-2 scores (r=0.31, p=0.00) in children with konzo. Elemental deficiency was not associated with poor cognition. Mean (SD) urinary level of thiocyanate was 388.03 (221.75) µmol/l in non-konzo compared to 518.59 (354.19) µmol/l in konzo children (p<0.01). Motor deficits associated with konzo may possibly be driven by the combined effects of cyanide toxicity and Se deficiency on prooxidant mechanisms. Strategies to prevent konzo may include dietary supplementation with trace elements, preferentially, those with antioxidant and cyanide-scavenging properties.

Control of konzo by detoxification of cassava flour in three villages in the Democratic Republic of Congo.

Three villages in Boko Health Zone, Bandundu Province, Democratic Republic of Congo (DRC), had 61 konzo cases and konzo prevalences of 2.5%, 4.1% and 7.5% respectively. Konzo cases occurred every year for 10 years and every month, peaking in July. The high mean cyanide content of cassava flour of 50 ppm was due to short soaking of cassava roots for 1-2 days instead of 3-4 days. Konzo cases were examined and village women taught the wetting method that removes cyanogens from flour. The villages were visited every month for 1 year following previous methodology. No new konzo cases occurred during the intervention, mean flour cyanide levels reduced from 50 to 14 ppm and mean urinary thiocyanate levels of school children reduced from 930 to 150 µmole/L. The percentage of children with urinary thiocyanate levels of >350 µmole/L was reduced from a maximum of 80 in Ikialala before the intervention to 0 in Ikusama, Ikialala and 3 in Imboso Mwanga 1 year later. This is the second time that konzo has been controlled and success depends on regular use of the wetting method by village women. The methodology is now being used in other villages in DRC with financial support of AusAID.

Control of konzo in DRC using the wetting method on cassava flour.

Fifty konzo cases were identified in four villages in Popokabaka Health Zone, DRC. One third of people had only one meal per day, mainly of cassava flour consumed as a thick porridge (fufu) and pounded, boiled cassava leaves. Retention of cyanogens in flour resulted from short soaking of cassava roots. A 1.5 years intervention was made in the largest village Kay Kalenge, where the wetting method was taught to all women of the village, who accepted it willingly. The total cyanide content of cassava flour was reduced to below 10 ppm. Fufu from treated flour tasted and stored better than fufu from untreated flour. The mean urinary thiocyanate content of 100 school children reduced from 332 to 130 µmole/L and the number of samples exceeding 350 µmole/L decreased from 26 to 0 during the intervention. No new konzo cases occurred, which included two dry seasons when konzo peaks. Konzo was first identified by Dr. Trolli in 1938 in Popokabaka Health Zone and it has now been prevented for the first time in the same area. The methodology is now in use in Boko Health Zone and we believe it is the most effective way to control konzo in tropical Africa.