I believe these are the infamous "AES" cases. Heat stroke has previously been mentioned as a possible cause for this illness.
http://www.promedmail.org/direct.php?id=20130923.1963903
Published Date: 2013-09-23 22:44:33
Subject: PRO/EDR> Undiagnosed illness, children - India (02): (BR) RFI
Archive Number: 20130923.1963903
UNDIAGNOSED ILLNESS, CHILDREN - INDIA (02): (BEHAR) REQUEST FOR INFORMATION
***************************************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org
Date: Sun 22 Sep 2013
Source: The Indian Express [summarized & edited]
http://www.indianexpress.com/news/whats-ailing-the-bihars-children-/1172414/
Every year, 3 months before the monsoon arrives, 900 and 1200 children between the ages of 2-5 are afflicted with a mystery illness. It starts with lethargy and a light fever but shows the 1st signs of worsening towards the morning. Many of the children are dead before they can reach a hospital.
The district saw 44 deaths in 2011, 121 in 2012, and 39 this year [2013]. Bihar Health Secretary Sanjay Kumar admits they don't know the reason for this decline. "The cases have dropped this year " he says. "We don't know what we have done right. Right now, we are all groping in the dark."
The latest to draw a blank is a team from the Centers for Disease Control (CDC) in Atlanta, USA, which was roped in by the National Centre for Disease Control (NCDC) to test samples from this year [2013]. A report submitted to the state and Centre by the NCDC in the 1st week of September 2013 said the results have been negative for several known viruses, including Japanese encephalitis (JE), enteroviruses, West Nile virus, dengue, Chandipura and Nipah. In fact, after testing blood samples, rectal swabs and cereobrospinal fluids of patients, as well as brain tissues collected from deceased patients, researchers have not been able to isolate a single strand of a virus. The question now staring them in the face is: is it even a virus?
When the 1st locally tested samples tested negative for JE virus, tests were repeated by multiple agencies last year [2012] and again this year [2013], including the National Institute of Virology in Pune, the NCDC in Delhi, units of the Indian Council of Medical Research such as Patna's Rajiv Memorial Research Institute (RMRI), Delhi's Safdarjung Hospital and Lady Hardinge Medical College, and a team from the CDC, Atlanta. However, all ruled out JE [virus infections].
"Since the disease was not found in patients, we decided to look for it in the vectors, mosquitoes which carry the JE virus from hosts such as pigs, water birds or other livestock to humans," says Dr Pradip Das, director of RMRI. However, no known vector of JE was found on the scene. "Now, we have eliminated the theory of JE [virus] completely," Dr Das says. The RMRI and NCDC conducted similar tests, but to no avail.
Admits Dr Das: "There are several characteristics which make this disease different. JE is a post-monsoon disease, while all the cases here are seen before the rains.
There are other differences: in Gorakhpur, deaths occur within 48-72 hours of convulsions, while in Muzaffarpur, mortality strikes within a few hours of the 1st convulsions.
While the treatment is symptomatic, with doctors managing convulsions with anti-convulsant drugs like Diazepam and fever with paracetamol, in Gorakhpur, other symptoms like internal bleeding, respiratory failure, kidney failure and compromised heart functions assume more importance, Dr Kushwaha adds.
The CDC-NCDC team that went to Muzaffarpur this year [2013] included one of the world's only neurologist-epidemiologists, Dr James J Sejvar, from Atlanta. He was called in as clinicians started looking for more patterns for clues, and noticed increasing neurological symptoms: nausea, seizures, unconsciousness and, in a few, altered brain function. Data from this year shows that 98 per cent of the patients in Muzaffarpur reported generalised seizures, and 85 per cent had loss of consciousness, with 40 per cent having documented fever.
More specialists were brought in, and new investigations to test brain functions were introduced this year [2013]. Samples of cerebrospinal fluid -- the fluid circulating in the spinal cord -- were collected through lumbar puncture, and CT scans were done on all children, funded by the state government.
Other national agencies in previous years had collected their own samples, including 2 samples of brain tissue from deceased patients taken by the NIV in Pune last year [2012]. The results were baffling. All cerebrospinal samples were found to be clear, while the brain tissue held no answers either.
The CDC Atlanta examined MRIs of 10 children and reported no signs of inflammation in the brain tissue, according to preliminary findings published in an NCDC quarterly newsletter. "In fact, there were no signs of any infection at all in the CSF. This throws up a huge question. We don't know if any [infectious] pathogen is involved at all. That could mean our search for viruses as possible causative factors has been in the wrong direction," Dr Das says.
"Liver function tests and kidney function tests on patients to test for toxins have all been negative, with no evidence of absorption of any poisonous agent from fruit or otherwise," Dr Singh says.
Scientists then turned to the environment for clues, looking for triggers that came annually. Heat was picked as one such factor. Doctors at the Sri Krishna Medical College (SKMC) in Muzaffarpur, which has treated the 2nd highest number of cases this year [2013], have published 2 articles -- notably the only peer-reviewed medical publications from the area so far -- saying that high temperatures and peak humidity could be leading to heat strokes, which if untreated for long periods may be contributing to the exaggerated symptoms.
"In India, since the JE virus is the most recognised common cause of encephalitis, especially in an outbreak, physicians and public health and administrative officials have a tendency to attribute all the epidemics of febrile convulsive disorder in children to this virus," the authors state in the July 2013 issue of the Annals of Tropical Medicine and Public Health.
Noting that "no infective organism or its antigen or antibody was found in any of the samples tested," the authors say that the "overall picture of these cases was suggestive of heat stroke." Other clinicians, however, discount this theory, stating that episodes of heat strokes cannot be seen in the hours of the morning [well before dawn], the time when most children take a turn for the worse.
The National Institute of Occupational Health in Ahmedabad is already conducting tests to study the levels of an enzyme known as cholinesterase that is necessary to return neurons to their resting phases after activation.
The children are all malnourished.
--
Communicated by:
Ronan Kelly
Senior Moderator, FluTrackers<ronankelly@comcast.net>
[It appears that infectious agents have been excluded in the diagnosis of these cases. This report does not indicate which environmental toxicants have been tested for, with negative results. Similarly, there is some doubt about heat stroke as the causative factor in these cases. ProMED would appreciate receiving additional reports relating to the causative factors involved in these unfortunate cases.
http://www.promedmail.org/direct.php?id=20130923.1963903
Published Date: 2013-09-23 22:44:33
Subject: PRO/EDR> Undiagnosed illness, children - India (02): (BR) RFI
Archive Number: 20130923.1963903
UNDIAGNOSED ILLNESS, CHILDREN - INDIA (02): (BEHAR) REQUEST FOR INFORMATION
***************************************************************************
A ProMED-mail post
http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org
Date: Sun 22 Sep 2013
Source: The Indian Express [summarized & edited]
http://www.indianexpress.com/news/whats-ailing-the-bihars-children-/1172414/
Every year, 3 months before the monsoon arrives, 900 and 1200 children between the ages of 2-5 are afflicted with a mystery illness. It starts with lethargy and a light fever but shows the 1st signs of worsening towards the morning. Many of the children are dead before they can reach a hospital.
The district saw 44 deaths in 2011, 121 in 2012, and 39 this year [2013]. Bihar Health Secretary Sanjay Kumar admits they don't know the reason for this decline. "The cases have dropped this year " he says. "We don't know what we have done right. Right now, we are all groping in the dark."
The latest to draw a blank is a team from the Centers for Disease Control (CDC) in Atlanta, USA, which was roped in by the National Centre for Disease Control (NCDC) to test samples from this year [2013]. A report submitted to the state and Centre by the NCDC in the 1st week of September 2013 said the results have been negative for several known viruses, including Japanese encephalitis (JE), enteroviruses, West Nile virus, dengue, Chandipura and Nipah. In fact, after testing blood samples, rectal swabs and cereobrospinal fluids of patients, as well as brain tissues collected from deceased patients, researchers have not been able to isolate a single strand of a virus. The question now staring them in the face is: is it even a virus?
When the 1st locally tested samples tested negative for JE virus, tests were repeated by multiple agencies last year [2012] and again this year [2013], including the National Institute of Virology in Pune, the NCDC in Delhi, units of the Indian Council of Medical Research such as Patna's Rajiv Memorial Research Institute (RMRI), Delhi's Safdarjung Hospital and Lady Hardinge Medical College, and a team from the CDC, Atlanta. However, all ruled out JE [virus infections].
"Since the disease was not found in patients, we decided to look for it in the vectors, mosquitoes which carry the JE virus from hosts such as pigs, water birds or other livestock to humans," says Dr Pradip Das, director of RMRI. However, no known vector of JE was found on the scene. "Now, we have eliminated the theory of JE [virus] completely," Dr Das says. The RMRI and NCDC conducted similar tests, but to no avail.
Admits Dr Das: "There are several characteristics which make this disease different. JE is a post-monsoon disease, while all the cases here are seen before the rains.
There are other differences: in Gorakhpur, deaths occur within 48-72 hours of convulsions, while in Muzaffarpur, mortality strikes within a few hours of the 1st convulsions.
While the treatment is symptomatic, with doctors managing convulsions with anti-convulsant drugs like Diazepam and fever with paracetamol, in Gorakhpur, other symptoms like internal bleeding, respiratory failure, kidney failure and compromised heart functions assume more importance, Dr Kushwaha adds.
The CDC-NCDC team that went to Muzaffarpur this year [2013] included one of the world's only neurologist-epidemiologists, Dr James J Sejvar, from Atlanta. He was called in as clinicians started looking for more patterns for clues, and noticed increasing neurological symptoms: nausea, seizures, unconsciousness and, in a few, altered brain function. Data from this year shows that 98 per cent of the patients in Muzaffarpur reported generalised seizures, and 85 per cent had loss of consciousness, with 40 per cent having documented fever.
More specialists were brought in, and new investigations to test brain functions were introduced this year [2013]. Samples of cerebrospinal fluid -- the fluid circulating in the spinal cord -- were collected through lumbar puncture, and CT scans were done on all children, funded by the state government.
Other national agencies in previous years had collected their own samples, including 2 samples of brain tissue from deceased patients taken by the NIV in Pune last year [2012]. The results were baffling. All cerebrospinal samples were found to be clear, while the brain tissue held no answers either.
The CDC Atlanta examined MRIs of 10 children and reported no signs of inflammation in the brain tissue, according to preliminary findings published in an NCDC quarterly newsletter. "In fact, there were no signs of any infection at all in the CSF. This throws up a huge question. We don't know if any [infectious] pathogen is involved at all. That could mean our search for viruses as possible causative factors has been in the wrong direction," Dr Das says.
"Liver function tests and kidney function tests on patients to test for toxins have all been negative, with no evidence of absorption of any poisonous agent from fruit or otherwise," Dr Singh says.
Scientists then turned to the environment for clues, looking for triggers that came annually. Heat was picked as one such factor. Doctors at the Sri Krishna Medical College (SKMC) in Muzaffarpur, which has treated the 2nd highest number of cases this year [2013], have published 2 articles -- notably the only peer-reviewed medical publications from the area so far -- saying that high temperatures and peak humidity could be leading to heat strokes, which if untreated for long periods may be contributing to the exaggerated symptoms.
"In India, since the JE virus is the most recognised common cause of encephalitis, especially in an outbreak, physicians and public health and administrative officials have a tendency to attribute all the epidemics of febrile convulsive disorder in children to this virus," the authors state in the July 2013 issue of the Annals of Tropical Medicine and Public Health.
Noting that "no infective organism or its antigen or antibody was found in any of the samples tested," the authors say that the "overall picture of these cases was suggestive of heat stroke." Other clinicians, however, discount this theory, stating that episodes of heat strokes cannot be seen in the hours of the morning [well before dawn], the time when most children take a turn for the worse.
The National Institute of Occupational Health in Ahmedabad is already conducting tests to study the levels of an enzyme known as cholinesterase that is necessary to return neurons to their resting phases after activation.
The children are all malnourished.
--
Communicated by:
Ronan Kelly
Senior Moderator, FluTrackers<ronankelly@comcast.net>
[It appears that infectious agents have been excluded in the diagnosis of these cases. This report does not indicate which environmental toxicants have been tested for, with negative results. Similarly, there is some doubt about heat stroke as the causative factor in these cases. ProMED would appreciate receiving additional reports relating to the causative factors involved in these unfortunate cases.
