The Epidemic of Encepahalitis at Muzzafarpur: An Itrogenic disease -An Extrapyramidal Syndrome

Virus has no affection neither for the poor class of children nor for Muzaffarpur. Viral  epidemic involves generally vast areas. Very Recently in the past Bangladesh conjunctivitis involved many provinces and countries .

This type of epidemic at Muzaffarpur has occurred many times in the last 15 years  and everytime blood samples were sent to specialized centres at distance places. But never came to be positive, which proves that it is not encephalitis.

I have had just a glimpse of few cases on television. And I strongly  believe that these are the cases of Extrapyramidal syndrome. Due to the toxicity of antiemetic, the phenothiazine group of drugs. And can be called as a Phenothiazine disaster.

The Phenothiazine comprises some of the most widely used tranquilizers such as Chlorpromazine, Promazine, Triflupromazine, prochlorperzine, perphaenazine, fluphenazine, thoridazine, trifluoperazine. In addition of sedative effects of the group of drugs they have a number of other actions, so that derivatives of these compounds are used as antiemetic and antihiatamines.

Side effect of Phenothiazine are frequent and often very serious may prove to be fatal. All of them may cause cholestatic jaundice, agranulocytsis, Convulsive seizures, tremors, orthostatic hypotension, skin sensitivity reaction, mental depression and disorder of the extrapyramidal motor system known as extrapyramidal syndrome and have been relatively more pronounced. Several type of extrapyramidal  syndrome have been noticed but the cases of Muzaffarpur are concerned with muscle spasm and dystonia, taking the form of

1.       Involuntary movement of the face

2.       Protrusion of tongue

3.       Oculogyric crises

4.       Dysphagia

5.       Torticollis

6.       Rectrocollis

7.       Tonic spasm of the limbs

And are confused with encepahalitis and meningitis, if the neck muscles are soft encephalitis, if the neck muscles are stiff meningitis.

Mind u even a single doze of phenothiazine derivatives can cause

1.       extrapyramidal syndrome

2.       jaundice and hepatic coma ( liver failure)

and both can simulate Encephalitis.

Diagnosis lies only in taking proper history of taking antiemetics & knowledge of extrapyramidal syndrome. Tests are done only to exclude meningitis and encepahalitis.

One great philiosopher has said that – “ eyes don’t see what the mind doesn’t know.”

Shushrutha, the father of modern surgery has written in sanskrit that a man cannot be true surgeon without the knowledge of medicine and a man cannot be a true  physician without the knowledge of all the disciplines of medicines.

Please look into what happens, poor children suffer from the problem of round worm manifestation and their  abdomen are rather filled with round worm which causes many medical and surgical problem in our day to day practice. When poor children run and play in the scorching sun and eat unripe lichi and mango which are acidic in nature. ( Muzaffarpur  is known not only in India but in the whole world for its Lichi and mangoes.) it not only increases the peristalsis of G.I.T  but also irritates the worms and they become mobile and try to find way out through the anus and the mouth and this causes attack of diarrhoea and vomiting and they get dehydrated very soon. Then they are brought to quacks and medical shops for treatment. They give them antiemetics and story of encephalitis begins. Then they visit some doctor at local hospital for excessive vomiting and they repeat the dose of phenothiazine and the condition is so worsened that they are left with no other option other than the Sadar hospital or medical college hospitals. Bruce Lee, the steel man, father of Jeet kunido of Hong Kong died of a single dose of analgesic what to talk of poor children. Bihar has also topped the list in Misusing drugs.  Here everybody is a doctor himself and there is an open market for medicine.You can have any medicine from any counter.

 The Phenothiazine group of drugs cause toxicity even in a single dose but in presence of dehydration and malnutrition it becomes very very toxic resulting in the features of extrapyramidal syndrome.which is not easy to diagnose even for the bald-headed physicians  what to talk of surgeons and others.

It is worth noting that in dehydration &in renal failure the normal therapeutic dose of drug becomes very very toxic and much more hazardous.

Round worms can alone create encephalitic feature, cough fever and dysphagia are also due to round worms-broncho-pneumonia.

Froth coming out of mouth is due to the development of pulmonary oedema and is taken as omen of death and is caused by excessive infusion and is a very serious medical emergency.

As heat regulating centres in kids are not well developed and children are also malnourished so even low grade pyrexia is converted into hyperpyrexia with convulsions  and simulates encephalitis.

A)     Heat strokes can simulate encephalitis

B)      At first look any convulsive fever is thought to be encephalitis.

C)      Repeated convulsion without fever due to round worm is wrongly taken as epilepsy.

It is true that Children tolerate trauma well but the things that they are intolerant to are

1.       Water and electrolyte imbalance & dehydration

2.       Over hydration

3.       Overmedication

All serious patient don’t always require costly medicine and too much of I.V. Infusion but what is required is your full attention, keen observation and full dedication.

At the end of 18^thcentury there was a flu epidemic in England. Doctors prescribed paracetamol to every patient, paracetamol is also euphoric and promotes a sense of well being in every patient. So many patients continued taking paracetamol even after their full recovery.After a lapse of month there was another epidemic of kidney failure. After the discovery of the underlying reason, sale of the drug without proper prescription  was banned. This type of epidemic never repeated in England.Here in India Quacks are rampant and there is no restriction in the sales of drugs.

Even doctors can't believe and realise that a drug can cause an epidemic,what to talk to people in general, in 1960-61 in West Germany an outbreak of Phocomelia occurred. Phocomelia means “seal extremities” it is a congenital deformities in which the long bones of the limbs are defective and substantially normal or rudimentary hands and feet arise on ,or nearly on the trunk, like the flipper  of a seal.

In a series of 46 cases of phocomelia it was found that 41 mothers had certainly taken thalidomide and of 300 mothers with normal babies none had taken thalidomide in between 4^thand 9^th week of pregnancy. Doctors found the root cause of phocmelia as the use of thalidomide as a sedative and hypnotics by the mothers. The West German health ministry estimated that thalidomide caused about 10000 birth deformities in babies, 5000 of whom survived and 1600 of whom eventually need artificial limbs. In Britain there were at least 600 live births of malformed children of whom about 400 survived. In 1960-61 it had become evident that prolonged use of thalidomide had caused phocomelia, hypothyroidism and peripheral neuritis. And hence the government ordered for withdrawl of this drug from the market. In West Germany from Nov 1961 and in Britain from Dec 1961. This type of epidemic of phocomelia never occurred after withdrawl of Thalidomide.