Cassava toxicity
Epidemic flaccid paralysis in Burundi Michael H.N. Golden 22.04.97
Re: Epidemic flaccid paralysis in Burundi Dan Ramdath 23.04.97
Re: Epidemic flaccid paralysis in Burundi Saskia V.D. KAM 24.04.97
cassava toxicity Michael H.N. Golden 24.04.97
Epidemic flaccid paralysis in Burundi Thorkild Tylleskar 24.04.97
Epidemic flaccid paralysis in Burundi (fwd) -Reply Rita Bhatia 25.04.97
Flaccid paralysis in Burundi Saskia V.D. KAM 04.06.97
Flaccid paralysis in Burundi Michael H.N. Golden 04.06.97
Flaccid paralysis in rfugees Michael H.N. Golden 28.04.97


Tue, 22 Apr 1997 11:52:31 +0100 (BST)

Subject: Epidemic flaccid paralysis in Burundi.

From: "Michael H.N. Golden" <m.goldenatabdn.ac.uk>

 

I forward a message from Yvonne Grellety, ACF, and wonder if anyone on the list can help. In particular Torkild Tyllescor and Hans Rosling from Uppsala who have worked in neurological illness in African villages, and clinicians on the list.

>Yvonne Greletty says :

>Dear Mike,

Some news from Maramvya, Burundi : 18.04.97.

2. There is another new problem : 40 adults suffer from a " limp paralysis" with the incapacity of walking, painfull paresthesia speciallly in the calf muscle, absence of rotule (knee) reflex, no babinski, no fever, no cardiac or pulmonary signs, no signs of malnutrition. They said that they eat fish, beans, spinach, fruits, oil and cassava (which was correctly prepared and dried for 3 days before cooking). But , after asking two patients on what kind of food they were eating : they told them that they were eating for 2-3 days raw cassava roots one month ago after they evacuated for security reasons the village of Gitaza, near the lake, south of Bujumbura.

Questions :

What do think about this ?

Could it be intoxication coming from raw cassava ?

What is your suggestion for the treatment of this if it's the case ?

And what to do if not ?

Yvonne

 

Dear Yvonne,

This is not the way that poisoning with cassava ususally presents - Hans Rosling's group has described this in detail: it is called Konzo: there is a sudden onset of spastic paraparesis affecting mainly women and adolescents. There is NO flaccid phase to the illness, the reflexes are exagerated with clonus, strongly planter-flexed feet and a sissors-gait in those that can stand. It is not progressive. There are no sensory signs or symptoms. Hans and Torkild may correct me but from the descriptions it is very unlikely to be Cassava poisoning.

As the paralasis is SYMETRICAL (Yvonne told me this on the phone) it is not polio-myelitis.

I am unsure what would present in this way with parasthesia in the lower leg and flaccid paralysis in a sudden epidemic form, affecting the non-anthropometrically-malnourished

people in the camp. It is most likely an intooxication or infection. It does not sound like a vitamin deficiency. I do not know of any infection that presents with symetrical paralysis in this way (help clinicians on the list). Many of the intoxicants that are well described (like lead poisoning for example) are not usually in epidemic form as a pure lower-limb flaccid paralysis without any other neurological or systemic signs. I wonder if this population which has been hiding in the "bush" has been taking any "unusual" plants to eat that are not part of the normal diet (a bit like the liver problems that we saw in Tubmanbourg).

Clearly, the subjects should have a full and comprehensive physical examination to describe the syndrome in detail and a full history of the exact time of onset and the way and order in which the symptoms have evolved, in relation to their intake of "unusual" items. We should also collect the detailed epidemiology of this outbreak, (who when where data). Please ask the Doctor there to also collect data of the intake, diet etc, of similar people who were not affected (like a case control study) by the paralysis. We will also need to document the course of the illness (does it improve or deteriorate etc) and the evolution of the epidemic - are there new cases occuring. I know that this will be difficult becasue the people wish to leave the centre, however, with the present information I do not think that we can reach a reasonable hypothesis as to the actual cause.

Have any of the others working in Cental Africa seen this before? Have any of the other NGOs seen this in the sectors that they are working in?

Best wishes,

 

Prof. Michael H.N.Golden


Wed, 23 Apr 97 13:49:02 PST

Subject: Re: Epidemic flaccid paralysis in Burundi.

From: dramdathatmedsci.uwi.tt (Dr. Dan Ramdath)

 

I am not sure if this will help but this reminds me of lathyrism due to comsumption of unprocessed chick peas. The toxin acts on the dorsal horn cells and leads to progressive paralysis and calf muscle atrophy. What type bean is eaten and how is it processed? and how frequently is is it eaten?

Dan Ramdath

 

-------------------------------------------------------------------------------

Eric Williams

THE UNIVERSITY OF THE WEST INDIES

Faculty of Medical Sciences Department of Biochemistry, Medical Sciences Complex

Champs Fleurs, Trinidad & Tobago, West Indies.

Phone:(809) 645-2640 Ext4644, Fax: (809), 663-9836Email:dramdathatmedsci.uwi.tt


From: sakatamsterdam.msf.org (Saskia V.D. KAM)

Subject: Re: Epidemic flaccid paralysis in Burundi.

Cc: Hans.Roslingatphs.ki.se (Hans Rosling)

 

Subject 'epidemic paralysis" in Burundi

Dear Yvonne,

This looks like "konzo" or intoxication of cyanide from casava.

You can look up the following literature:

=> WHO: Releve Epidemiologique Hebdomadaire; 1996, 71, 225-232

=> Konzo à Mogincual, Mozambique: Medical News (MSF) decembre 1993, vol2, no6

=> Haute prevalence de Konzo associee a une crise agro-alimentaire dans la région de Bandunu au Zaire: Ann.Soc.belge Méd.trop. 1992, 72, 295-309

More information on internet:

http://www2.uu.se/insts/nutrition/konzo

In principle the paralysis is permanent.

There is no drug treatment:

vit B is recommended, and a good balanced diet, casava free. additional a programme with physio-therapy.

prevention is cricial.

Bye, Saskia


Thu, 24 Apr 1997 12:13:26 +0100 (BST)

Subject: cassava toxicity

From: Prof. Michael H.N.Golden

 

Saskia's comments are germaine and refugees in famine conditions that "take to the forrest" are very likely to eat both abnormal plants and also to skip the necessary steps in processing cassava. Linley Karlton in Uppsala has done a lovely study which shows that the reason for chosing very toxic varieties of casssava are to prevent theft from the grower - it is likely that in areas of great instability where soldiers are likely to try to reap the farmers crops that the toxic varieties are grown. For these reasons we should all be aware of the effects of Cassava toxicity and be able to recognise Konzo.

However!

The clinical features of Konzo are quite different from the descriptions that Yvonne Grellety gives for the patients in Burundi. In Konzo, there is a sudden onset of non-progressive, permanent, spastic paraparesis, with exaggerated knee and ankle reflexes. The conditions are thus not the same clinically. On the other hand, the question does arise as to whether plants, such as cassava, with cyanogenic compounds in them can also give a flaccid paralysis.

I have spoken to Yvonne and further information is that the patients do not give a history of eating plants that are not normally used as food in this region.

Could Hans Rosling or Torkild Tylleskar (it was this group that described Konzo initially and now study cassava toxicity as their main research program) please comment on other clinical presentations of cassava toxicity, and on the differential diagnosis of epidemic symetrical flaccid paralysis under famine conditions.

Best wishes,

Prof. Michael H.N.Golden


Thu, 24 Apr 1997 15:55:23 +0100 (BST) Message-Id:

Subject: Epidemic flaccid paralysis in Burundi (fwd)

From: "Michael H.N. Golden" <m.goldenatabdn.ac.uk>

 

This is the response sent to me by the Konzo group!

>Thorkild Tylleskar says :

>Dear Mike,

Regarding the report of paralysis from Burundi: I would treat the patients with Multi-B-vitamins to avoid any (inter)action from any deficiency of these vitamins. This kind of deficiency might not be the cause but it is still possible to be an aggravating factor to be avoided.

It is difficult to give any diagnosis on the present description other than it is not konzo.

Best regards,

Thorkild Tylleskar

_____________________________________________________

Thorkild Tylleskar, MD, PhD

International Child Health (ICH)

Department of Nutrition, Department of Pediatrics

Uppsala University Uppsala University Hospital

Dag Hammarskjolds vag 21 S-751 85 UPPSALA

S-752 37 UPPSALA, SWEDEN SWEDEN

--------------------------------------------------------------------------- Incidentally, Lathyrism is usually also a spastic paralysis with exagerated reflexes and a sissors gait, I do not think that this explaination is sufficient.

Best wishes,

 

Prof. Michael H.N.Golden


Date: Fri, 25 Apr 1997 19:57:39 +0200

From: Rita Bhatia <BHATIAatunhcr.ch>

Subject: Epidemic flaccid paralysis in Burundi (fwd) -Reply Sender:

 

Just to share my thoughts.

This reminds of Lathrysium .Bhutanese refugees in Nepal were given Yellow pulses which looks like Kesari Dal which causes Lathrysium and is banned in South Asia. However the symptoms were neurological paralysis etc. Be Beri was suspected. Treatment with Thiamine injection was useful. Of course Polished rice is the staple food in Nepal. This was later replaced with Parboiled rice.

Similar cases were seen in Thailand on the Thai.. Cambodian border eating wild forest food Cassava was one of them.

Recently in Kigoma Tanzania Zairian Refugees were picking up wild Mushrooms and poising cases were reported.

Awareness and good nutrition messages.

 

Rita


Date: Wed, 4 Jun 1997 15:16:32 +0100

From: sakatamsterdam.msf.org (Saskia V.D. KAM)

 

Dear NGO-Nuts

What happened to the flaccid paralysis epidemic in Burundi? Still waiting for the final

conclusion....

 

Saskia van der Kam

Médecins Sans Frontières Holland, Amsterdam


Subject: Flaccid paralysis in Burundi

Date: Wed, 4 Jun 1997 17:32:50 +0100 (BST)

From: "Michael H.N. Golden" <m.goldenatabdn.ac.uk>

 

I saw and examined two of the patients when I was in Maramvya - 17 and 40 year old females, living in the same house, both paralysed from the waist down.

Memory and higher functions seemed intact, no agnosia or dysarthria, no disorientation. No nystagmus or strabismus, light and accommodation reflexs normal, field of vision full, other crainial nerves normal, finger-nose movement perfect both eyes open and closed;no tremors.

Upper limbs - power 4/5 hand+forearm 5/5 arm+shoulder. Rapid hand pronation/supination and finger tapping slow; Joint position sense normal, sharp/blunt discrimination normal, 2 point discrimination forarm 5cm, hand 2cm, finger tip 5mm (symetrical). Reflexes all very sluggish, tone normal. Lower limbs - power 1/5 upper leg, 0/5 lowerleg + foot. Panter reflex absent, knee and ankle jerks absent, tone reasonably normal (not floppy or stiff), all modalities of cutaneous sensation absent - deep pain (achilles tendon squeeze) just felt.

Abdominal reflexes absent - hyperalgesia to light touch over lower abdomen and back at the level of about T11. Bladder and bowel function were normal. There did not seem to be any problem with autonomic function.

The 17 year old could manouver herself into a hands-and-knees position and just about crawl dragging her legs the 40year old could not.

They reported that the disease had come on slowly over about 2 weeks and had not or only slowly progressed since (4-6 weeks).

There were no other abnormal signs in the other systems, and the patients had now a good appetite and were otherwise healthy. They had not had a fever.

The clinical picture is that of a transverse myelitis. I understand from Paul Eunson (paediatric Neurologist in Edinburgh) that there was a similar outbreak in SE Asia some years ago that was thought to be viral.

At any rate it is not like TSP, Konzo, Lathyrism, Beri-beri or heavy metal poisoning.

Best wishes,

 

Prof. Michael H.N.Golden


Mon, 28 Apr 1997 10:59:09 +0100 (BST)

Subject: flaccid paralysis in refugees

From: "Michael H.N. Golden" <m.goldenatabdn.ac.uk>

 

Dan Ramdath and Rita Bhatia both suggest that the flaccid paralysis seen in Burundi could be due to lathryism. However, lathryism gives a spastic paraparesis not a flaccid paraparesis.

Thus, I do not think this fits-the-bill.

Nevertheless, it is very difficult to differentiate the different species, varieties and cultivars of pulse from their appearance and lathryism is a very real threat where there is not adequate quality control. It is good to keep this possibility in mind.

Does Rita have any more data on the clinical presentation of the Zaireans that were poisoned by "mushrooms".

Best wishes,

 

Prof. Michael H.N.Golden