For over two decades, children in Bihar, a state along the eastern coast of India, have been suddenly dying due to unexpected seizures, and rapid loss of consciousness due to neurological damage.

Despite several investigations, the cause behind the devastating deaths seemed to be unknown. What was certain was that the seizures seemed to strike randomly, affecting one child at a time.

The culprit was finally identified, in a study published by The Lancet last month, which surprisingly pinpointed the seemingly harmless lychee fruit as the reason behind the tragic deaths of hundreds of malnourished children living in Muzarffarpur.

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The study analyzed 400 cases of children who developed the brain illness between May and July 2014, and compared the affected children with 100 children that did not develop the mysterious illness. Results showed that children with the brain illness were 10 times more likely to have eaten lychee, 24 hours before becoming ill, compared to those unaffected by the illness.

It was also observed that affected children were twice as likely to have eaten lychee on an empty stomach, than those who did not develop the illness. The sick children displayed exceedingly low blood sugar levels, and other signs indicating problems with their metabolism.

This particular finding, seemed to crack the mystifying puzzle. Upon not eating a meal, you experience a dip in blood sugar levels, the body is then equipped to handle this situation by metabolizing fatty acids to produce glucose for energy. The children who had missed a meal and then consumed lychees however, were unable to metabolize fatty acids due to certain toxins found in lychee, namely hypoglycin and methylenecyclopropyl glycine, or MCPG. These molecules disrupt the metabolism of fatty acids, contributing to extremely low blood sugar levels and subsequent brain inflammation and seizures.

The Muzaffarpur area in India, is responsible for 70% of India’s lychee harvest, and contains densely scattered lychee orchards around the affected villages. “The synergistic combination of [lychee] consumption, a missed evening meal, and other potential factors such as poor nutritional status and eating a greater number of lychees may be needed to produce the illness” researchers wrote in the Jan. 30 issue of the journal the Lancet Global Health.

Preventing More Child Deaths Muzaffarpur

Since the findings were made apparent in 2015, it was advised by researchers that the children affected by the disease be immediately treated for hypoglycemia, or low blood sugar levels. Researchers also urged parents to ensure children consume evening meals, and limit their intake of lychees.

The simple solution was embraced by villagers, and has been shown to have a positive effect on vulnerable populations. It was reported by The Times, that over the last two seasons, the number of reported cases in Muzaffarpur have reduced from hundreds each year, to about 50.

Despite perhaps not having bursting lychee trees in our backyard, it should be noted that lychee is not to be eaten on an empty stomach. Which isn’t to say there aren’t other fruit combinations that will satisfy a grumbling stomach!

Shrivastava, A., Kumar, A., Thomas, J. D., Laserson, K. F., Bhushan, G., Carter, M. D., … & Dwivedi, M. (2017). Association of acute toxic encephalopathy with litchi consumption in an outbreak in Muzaffarpur, India, 2014: a case-control study. The Lancet Global Health.

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