INDIA ABROAD February 10, 2017 22 INDIA
By Salman Masood
; NEW DELHI
hree years ago, Dr.
Rajesh Yadav, an inves-
tigator with the India
Service, moved to the
city of Muzaffarpur, the
site of one of the country’s most
mysterious outbreaks. And he
Every year in mid-May, as
temperatures reached scorching
heights, parents took children
who had been healthy the night
before to the hospital. The children awakened with a high-pitch
cry in the early morning, many
Then the youths began having
seizures and slipping into comas.
In about 40 percent of cases,
Every year in July, with the
arrival of monsoon rains, the outbreak ended as suddenly as it
Beginning in 1995, investigations variously ascribed the phenomenon to heat stroke; to infections carried by rats, bats or sand
flies; or to pesticides used in the
region’s ubiquitous lychee
orchards. But there were few
signposts for investigators.
Instead of occurring in clusters, the illness typically struck
only one child in a village, often
leaving even siblings unaffected.
A joint investigation by India’s
National Center for Disease
Control and the India office of
the Centers for Disease Control
and Prevention in Atlanta, published in the British medical journal The Lancet Global Health on
Tuesday, has identified a surprising culprit: the lychee fruit itself,
when eaten on an empty stomach by malnourished children.
In 2015, as a result of the
investigation, health officials
began urging parents in the area
to be sure to feed young children
an evening meal and to limit
their consumption of lychees
(sometimes spelled litchi).
In two seasons, the number of
reported cases per year dropped
to less than 50 from hundreds.
“It was an unexplained illness
for so many years,” said Padmini
Srikantiah, a senior epidemiolo-
gist with the C.D.C. and the sen-
ior author of the paper. “This is
kind of emblematic of why we
collaborate, to build this kind of
The Lancet article walks
through a two-year medical
detective story, as epidemiolo-
gists like Dr. Yadav closely exam-
ined the lives of hundreds of
afflicted children, trying to
understand everything they had
eaten, drunk and breathed.
“It was a very intense situation, because we witnessed children dying in front of our eyes
every day, as soon as they
arrived at the hospital,” said Dr.
Yadav, who now works with the
C.D.C. in Atlanta. Especially difficult were the detailed interviews
of parents, many of whom had
carried a convulsing or comatose
child for hours to get to the hospital.
“They were in a kind of
panic,” he said. “Their children
were dying, and it was an
The first clue: There was no
evidence the children had infec-
For 20 years, clinicians were
unable to determine if the dis-
ease, which led to acute brain
swelling known as encephalopa-
thy, was caused by an infection —
the immediate assumption in
many outbreaks here.
Investigators pored over
records from the previous year’s
outbreak and were struck by the
fact that many of the sick chil-
dren did not have a fever.
Analysis of spinal fluid samples
overwhelmingly showed that the
affected children did not have
elevated counts of white blood
cells, a sign the body is fighting
The second clue: Most of the
victims had very low blood sugar
Having collected biological
samples from more than 300
children, the researchers were
able to scan a large number of
markers — including some they
Glucose had never been a particular concern for investigators.
But some of the affected children
had strikingly low levels, and
those with low blood glucose
were twice as likely to die, Dr.
“It seemed to be a little signal,” she continued. “One of the
things we heard multiple times
from the children’s mothers was
that they didn’t really eat dinner
Amrendar Kumar comforts his daughter Sanam Kumari, 2, at the Sri Krishna Medical College Hospital in Muzaffarpur,
June 24, 2013. Below, Sorting through lychees. The fruit has been blamed for causing sickness in children.
A joint investigation by India’s National Center for Disease Control and the India office of the
Centers for Disease Control and Prevention in Atlanta, has named the lychee as the culprit
Continued on page 23
Mystery of Deadly Outbreaks Is Solved