Indian Pediatrics - Editorial

Letters to the Editor

Indian Pediatrics 2003; 40:920-922

Brief Profile of an Epidemic of Acute Encephalopathy in Western Uttar Pradesh

During the months of October and November 2002, most of the towns of western Uttar Pradesh (U.P.) and few neighboring towns of Uttranchal state, witnessed a large outbreak of a mysterious illness that killed more than 100 children over a span of two months(1). Ninetten such children were also admitted to a secondary level private hospital in Bijnor district of western U.P. during the same period of the year. A brief profile of the illness in these cases is being presented. The acute encephalopathy involved children from age group of 2-14 years (median age 3.5 years). Almost all the cases were hailing from rural and suburban areas and most belonged to low socio-economic background. Following clinical criteria were used to select a case of acute encephalopathy:

(i) rapid onset of unconsciousness in a previously healthy child after a brief history of fever and vomiting:

(ii) absence of significant fever and jaundice at the time of presentation.

(iii) more than six folds rise in the liver enzyme levels, and low serum glucose level; and

(iv) normal cerebrospinal fluid examination.

The main presenting features were history of fever (78.9%) and profuse vomiting (94.7%), which was soon followed by abnormal behavior and agitation (84.3%), and sudden onset of unconsciousness (100%). Frank convulsions or history of seizures was found in 5 (26.3%) cases. The total duration of illness before presentation was less than 48 hours in 11 (57.9%) cases. Frank hematemesis and other signs of gastrointestinal bleeding were seen in only 4 (21.1%) cases. There was no history of rash or other overt signs of any exanthematous viral illness. History of measles vaccination was not available in all the cases. None of the children was given aspirin or any other medication containing salicylates. On investigation, serum amino-transferases (AST and ALT) were raised more than 6 times (mean values AST-3208.4 IU/L; ALT-3064.2 IU/L) of normal in all the children, whereas serum glucose conentration was found low in 18 (94.7%) cases. Serum bilirubin level was marginally raised in only 3 (15.8%) cases but none had clinical jaundices at the time of presentation. Markedly abnormal coagulogram and normal cerebrospinal fluid (CSF) examination were observed in all the nineteen children. As most of the children were from very low socio-economic strata of the community, detailed investigations could be performed in only two children. In these cases, IgM antibodies against measles were found in serum in one case and in both serum and in CSF in another. However, serum salicylates level, IgM anti-bodies against Hepatitis-A virus and Varicella zoster were negative. Liver biopsy could not be performed owing to deranged coagulation profile and low general condition of the cases. Sixteen (84.3%) out of 19 children succumbled to their illnesses and remaining 3 (15.7%) recovered. No neurological deficit was seen in the children who survived the disease.

The presentation and investigations of the cases did suggest a diagnosis of Reye’s syndrome (RS). The epidemiological and clinio-biochemical features of the cases enumerated above are quite closely resembled to the prifile of patient described in few other studies(2,3). We have been following this disease entity in the region since 1998, and so far have gathered information on 51 cases(4). However, this year’s outbreak was un-precedented both in its severity and vastness.

One very striking feature of the current epidemic was a very high mortality amongst the ill children(84.3%). The high case fatality rate can be attributed to involve- ment of comparatively younger age-group children(2,3) and probably a more severe form of the illness especially in an epidemic form.

The most significant finding of this year’s outbreak was presence of IgM antibodies against measles in two instances. This is to be noted that occurrence of measles during this time of the year is quite unusual. However, during a similar outbreak in Haryana during October-November 1997, the researchers confirmed the etiological role of measles by isolating measles virus from CSF and sera of six children with acute encephalopathy without rash(2,5). Another circumstantial evidence favoring measles as the causative organism is provided by the fact that routine immunization against measles and other UIP illnesses has gone down considerably in recent years (UNICEF, unpublished data) owing to over-emphasis given to Pulse Polio Immunization activities, lack of monitoring and supervision of routine immunization activities, and due to absence of detailed microplan and proper infrastructure in remote areas and urban slums in the state. Due to falling coverage, large cohorts of susceptible children are available for the measles virus to attack and propagate, and it might be possible for the virus to undergo genetic trans-formation in some malnourished and possibly immunocompromised hosts to trigger such a deadly albeit unusual epidemic.

Vipin M. Vashishtha,
Consulting Pediatrician,
Mangla Hospital, Shakti Chowk,
Bijnore 246 701, U.P., India.
E-mail: [email protected]

References

1. Mysterious fever toll 150. Hindustan Times 2002 December 12; Lucknow: p 4, (col 4,5).

2. Ghosh D, Dhadwal D, Aggarwal A, Mitra S, Garg SK, Kumar R. et al. Investigation of an epidemic of Reye’s syndrome in Northern regionof India. Indian Pediatr 1999; 36: 1097-1106.

3. Benakappa DG, Das S, Shankar SK, Rama Rao BSS, George PS, Awasthi PS. et al Reye’s syndrome in Bangalore. Indian J Pediatr 1991; 58: 805-810.

4. Vashishtha VM, Sharma JP. Reye’s syndrome-An interesting epidemiological correlation. Indian Pediatr 2000; 37: 343-344.

5. Wairagkar NS, Shaikh NJ, Ratho RK, Ghosh D, Mahajan RC, Singhi S, et al. Isolation of measles virus from cerebrospinal fluid of children with acute encephalopathy without rash. Indian Pediatr 2001; 38: 589-595.