BACKGROUND: Outbreaks of unexplained illness frequently remain under-investigated. In India, outbreaks of an acute @entity16 with high mortality among @entity1 occur annually in Muzaffarpur, the country's largest litchi cultivation region. In 2014, we aimed to investigate the cause and risk factors for this illness. METHODS: In this hospital-based surveillance and nested age-matched case-control study, we did laboratory investigations to assess potential infectious and non-infectious causes of this acute @entity16 . Cases were @entity1 aged 15 years or younger who were admitted to two hospitals in Muzaffarpur with new-onset @entity410 or altered sensorium. Age-matched controls were residents of Muzaffarpur who were admitted to the same two hospitals for a @entity16 within seven days of the date of admission of the case. Clinical specimens (blood, cerebrospinal fluid, and urine) and environmental specimens (litchis) were tested for evidence of infectious pathogens, pesticides, toxic metals, and other non-infectious causes, including presence of @entity68687 or @entity69265 ( @entity11722 ), naturally-occurring fruit-based toxins that cause hypoglycaemia and metabolic derangement. Matched and unmatched (controlling for age) bivariate analyses were done and risk factors for illness were expressed as matched odds ratios and odds ratios (unmatched analyses). FINDINGS: Between May 26, and July 17, 2014, 390 @entity1 meeting the case definition were admitted to the two referral hospitals in Muzaffarpur, of whom 122 (31%) died. On admission, 204 (62%) of 327 had blood @entity413 concentration of 70 mg/dL or less. 104 cases were compared with 104 age-matched hospital controls. Litchi consumption (matched odds ratio [mOR] 9  6 [95% CI 3  6 - 24]) and absence of an evening meal (2  2 [1  2-4  3]) in the 24 h preceding illness onset were associated with illness. The absence of an evening meal significantly modified the effect of eating litchis on illness (odds ratio [OR] 7  8 [95% CI 3  3-18  8], without evening meal; OR 3  6 [1  1-11  1] with an evening meal). Tests for infectious agents and pesticides were negative. Metabolites of @entity68687 , @entity11722 , or both were detected in 48 [66%] of 73 urine specimens from case- @entity1 and none from 15 controls; 72 (90%) of 80 case- @entity1 specimens had abnormal plasma @entity14992 profiles, consistent with severe disruption of @entity844 metabolism. In 36 litchi arils tested from Muzaffarpur, @entity68687 concentrations ranged from 12  4  g/g to 152  0  g/g and @entity11722 ranged from 44  9  g/g to 220  0  g/g. INTERPRETATION: Our investigation suggests an outbreak of acute @entity75 in Muzaffarpur associated with both @entity68687 and @entity11722 @entity137 . To prevent illness and reduce mortality in the region, we recommended minimising litchi consumption, ensuring receipt of an evening meal and implementing rapid @entity413 correction for suspected illness. A comprehensive investigative approach in Muzaffarpur led to timely public health recommendations, underscoring the importance of using systematic methods in other unexplained illness outbreaks. FUNDING: US Centers for Disease Control and Prevention.

Association of acute toxic XXXX with litchi consumption in an outbreak in Muzaffarpur, India, 2014: a case-control study.

@entity1 :: ('9606', 'Species') :: ['children', 'patients', 'patient'] @entity410 :: ('MESH:D012640', 'Disease') :: ['seizures'] @entity844 :: ('CHEBI:35366', 'Chemical') :: ['fatty acid'] @entity69265 :: ('MESH:C059830', 'Chemical') :: ['methylenecyclopropylglycine'] @entity11722 :: ('CHEBI:43876', 'Chemical') :: ['MCPG'] @entity137 :: ('MESH:D064420', 'Disease') :: ['toxicity'] @entity75 :: ('MESH:D001927', 'Disease') :: ['encephalopathy'] @entity16 :: ('MESH:D009422', 'Disease') :: ['non-neurologic illness', 'neurological illness'] @entity14992 :: ('MESH:C116917', 'Chemical') :: ['acylcarnitine'] @entity68687 :: ('MESH:C041757', 'Chemical') :: ['hypoglycin A'] @entity413 :: ('MESH:D005947', 'Chemical') :: ['glucose']
@entity75 :: (MESH:D001927,Disease) :: ['encephalopathy']
