Chandipura virus, encephalitis, and epidemic brain attack in India
2004; Elsevier BV; Volume: 364; Issue: 9452 Linguagem: Inglês
10.1016/s0140-6736(04)17579-x
ISSN1474-547X
Autores Tópico(s)Viral Infections and Vectors
ResumoThe report by B Rao and colleagues (Sept 4, p 869)1Rao BL Basu A Wairagkar NS et al.A large outbreak of acute encephalitis with high fatality rate in children in Andhra Pradesh, India, in 2003, associated with Chandipura virus.Lancet. 2004; 364: 869-874Summary Full Text Full Text PDF PubMed Scopus (142) Google Scholar details an outbreak of encephalitis associated with Chandipura virus in children in Andhra Pradesh, India, in June– September, 2003. However, in an analysis of the outbreak,2John TJ Outbreaks of killer brain disease: mystery or missed diagnosis?.Indian Pediatr. 2003; 40: 863-869PubMed Google Scholar I note the illness to be encephalopathy, not encephalitis. Typically, a rural child aged 2–15 years would go to bed normally, but wake up ill in the early hours of the next morning. Vomiting was followed by loss of consciousness that deteriorated to a deep coma and decerebrate posturing within several hours. Cerebrospinal fluid was clear, under pressure, and without pleocytosis. Many children died within 48–72 h of onset of symptoms. Early treatment with mannitol to reduce brain oedema was life saving. Also, in a report in the Journal of Pediatric Neurology,3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar the epidemic is not reported as encephalitis nor is the role of Chandipura virus confirmed.The authors of both reports1Rao BL Basu A Wairagkar NS et al.A large outbreak of acute encephalitis with high fatality rate in children in Andhra Pradesh, India, in 2003, associated with Chandipura virus.Lancet. 2004; 364: 869-874Summary Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar have done excellent work in their respective specialties—virology and neurology. The virological studies established Chandipura virus infection in some children, apparently leading to the conclusion that it caused the outbreak. A brain disease caused by viral infection ought to be called encephalitis, hence the outbreak was described as encephalitis. The detailed neurological findings and erudite argument by P N Rao and colleagues,3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar however, convincingly establish the outbreak as one caused by an acute catastrophic event in the brain.The illness mimics Reye's syndrome, with gross brain oedema, but there are important differences.3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar The site of the lesion was the area supplied by the middle cerebral artery.3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar There was no clinical evidence of invasion by a pathogen. The nature of the arterial pathology is likely to be spasm or transient obstruction due to vasculitis, rather than thromboembolism.3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar That such a disease could arise as an epidemic is new information.4Ismail HIHM Viruses and "epidemic brain attack": new agents, new challenges.J Pediatr Neurol. 2004; 2: 117-119Google Scholar If Chandipura virus is the cause, the disease is mediated via vasculitis, not encephalitis.3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar Otherwise another infectious agent, probably viral, might be involved.3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar, 4Ismail HIHM Viruses and "epidemic brain attack": new agents, new challenges.J Pediatr Neurol. 2004; 2: 117-119Google Scholar Infection is invoked to explain an epidemic.3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar, 4Ismail HIHM Viruses and "epidemic brain attack": new agents, new challenges.J Pediatr Neurol. 2004; 2: 117-119Google ScholarOutbreaks of acute encephalopathy with high case fatality reminiscent of this outbreak have been reported repeatedly in several northern Indian towns and villages.1Rao BL Basu A Wairagkar NS et al.A large outbreak of acute encephalitis with high fatality rate in children in Andhra Pradesh, India, in 2003, associated with Chandipura virus.Lancet. 2004; 364: 869-874Summary Full Text Full Text PDF PubMed Scopus (142) Google Scholar To assume an illness is infectious just because it affects a group of people could be misleading. Sriramachari5Sriramachari S Heat hyperpyrexia: time to act.Indian J Med Res. 2004; 119: vii-vixPubMed Google Scholar has suggested the clinical features of the recurrent encephalopathy outbreaks in northern India could be due to high environmental temperature, with or without secondary factors. He believes that the heat-related encephalopathy has all the brain features of Reye's syndrome. B Rao and colleagues1Rao BL Basu A Wairagkar NS et al.A large outbreak of acute encephalitis with high fatality rate in children in Andhra Pradesh, India, in 2003, associated with Chandipura virus.Lancet. 2004; 364: 869-874Summary Full Text Full Text PDF PubMed Scopus (142) Google Scholar note that the summer temperature in the outbreak region was 36–49°C. Both reports1Rao BL Basu A Wairagkar NS et al.A large outbreak of acute encephalitis with high fatality rate in children in Andhra Pradesh, India, in 2003, associated with Chandipura virus.Lancet. 2004; 364: 869-874Summary Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar state that fever was a consistent feature. Some children indeed had hyperpyrexia.1Rao BL Basu A Wairagkar NS et al.A large outbreak of acute encephalitis with high fatality rate in children in Andhra Pradesh, India, in 2003, associated with Chandipura virus.Lancet. 2004; 364: 869-874Summary Full Text Full Text PDF PubMed Scopus (142) Google Scholar Cases were widely scattered. The subject is well worth further research.Outbreak investigations are incomplete without the basics of epidemiology. Case definition should be made and applied. Epidemiological links between cases should be ascertained, and risk factors explored. India is not short of competence in medicine and research, but epidemiology skills, training, and field application are inadequate. The report by B Rao and colleagues (Sept 4, p 869)1Rao BL Basu A Wairagkar NS et al.A large outbreak of acute encephalitis with high fatality rate in children in Andhra Pradesh, India, in 2003, associated with Chandipura virus.Lancet. 2004; 364: 869-874Summary Full Text Full Text PDF PubMed Scopus (142) Google Scholar details an outbreak of encephalitis associated with Chandipura virus in children in Andhra Pradesh, India, in June– September, 2003. However, in an analysis of the outbreak,2John TJ Outbreaks of killer brain disease: mystery or missed diagnosis?.Indian Pediatr. 2003; 40: 863-869PubMed Google Scholar I note the illness to be encephalopathy, not encephalitis. Typically, a rural child aged 2–15 years would go to bed normally, but wake up ill in the early hours of the next morning. Vomiting was followed by loss of consciousness that deteriorated to a deep coma and decerebrate posturing within several hours. Cerebrospinal fluid was clear, under pressure, and without pleocytosis. Many children died within 48–72 h of onset of symptoms. Early treatment with mannitol to reduce brain oedema was life saving. Also, in a report in the Journal of Pediatric Neurology,3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar the epidemic is not reported as encephalitis nor is the role of Chandipura virus confirmed. The authors of both reports1Rao BL Basu A Wairagkar NS et al.A large outbreak of acute encephalitis with high fatality rate in children in Andhra Pradesh, India, in 2003, associated with Chandipura virus.Lancet. 2004; 364: 869-874Summary Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar have done excellent work in their respective specialties—virology and neurology. The virological studies established Chandipura virus infection in some children, apparently leading to the conclusion that it caused the outbreak. A brain disease caused by viral infection ought to be called encephalitis, hence the outbreak was described as encephalitis. The detailed neurological findings and erudite argument by P N Rao and colleagues,3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar however, convincingly establish the outbreak as one caused by an acute catastrophic event in the brain. The illness mimics Reye's syndrome, with gross brain oedema, but there are important differences.3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar The site of the lesion was the area supplied by the middle cerebral artery.3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar There was no clinical evidence of invasion by a pathogen. The nature of the arterial pathology is likely to be spasm or transient obstruction due to vasculitis, rather than thromboembolism.3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar That such a disease could arise as an epidemic is new information.4Ismail HIHM Viruses and "epidemic brain attack": new agents, new challenges.J Pediatr Neurol. 2004; 2: 117-119Google Scholar If Chandipura virus is the cause, the disease is mediated via vasculitis, not encephalitis.3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar Otherwise another infectious agent, probably viral, might be involved.3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar, 4Ismail HIHM Viruses and "epidemic brain attack": new agents, new challenges.J Pediatr Neurol. 2004; 2: 117-119Google Scholar Infection is invoked to explain an epidemic.3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar, 4Ismail HIHM Viruses and "epidemic brain attack": new agents, new challenges.J Pediatr Neurol. 2004; 2: 117-119Google Scholar Outbreaks of acute encephalopathy with high case fatality reminiscent of this outbreak have been reported repeatedly in several northern Indian towns and villages.1Rao BL Basu A Wairagkar NS et al.A large outbreak of acute encephalitis with high fatality rate in children in Andhra Pradesh, India, in 2003, associated with Chandipura virus.Lancet. 2004; 364: 869-874Summary Full Text Full Text PDF PubMed Scopus (142) Google Scholar To assume an illness is infectious just because it affects a group of people could be misleading. Sriramachari5Sriramachari S Heat hyperpyrexia: time to act.Indian J Med Res. 2004; 119: vii-vixPubMed Google Scholar has suggested the clinical features of the recurrent encephalopathy outbreaks in northern India could be due to high environmental temperature, with or without secondary factors. He believes that the heat-related encephalopathy has all the brain features of Reye's syndrome. B Rao and colleagues1Rao BL Basu A Wairagkar NS et al.A large outbreak of acute encephalitis with high fatality rate in children in Andhra Pradesh, India, in 2003, associated with Chandipura virus.Lancet. 2004; 364: 869-874Summary Full Text Full Text PDF PubMed Scopus (142) Google Scholar note that the summer temperature in the outbreak region was 36–49°C. Both reports1Rao BL Basu A Wairagkar NS et al.A large outbreak of acute encephalitis with high fatality rate in children in Andhra Pradesh, India, in 2003, associated with Chandipura virus.Lancet. 2004; 364: 869-874Summary Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 3Rao PN Kumar PA Rao TA et al.Role of Chandipura virus in an "epidemic brain attack" in Andhra Pradesh, India.J Pediatr Neurol. 2004; 2: 131-143Google Scholar state that fever was a consistent feature. Some children indeed had hyperpyrexia.1Rao BL Basu A Wairagkar NS et al.A large outbreak of acute encephalitis with high fatality rate in children in Andhra Pradesh, India, in 2003, associated with Chandipura virus.Lancet. 2004; 364: 869-874Summary Full Text Full Text PDF PubMed Scopus (142) Google Scholar Cases were widely scattered. The subject is well worth further research. Outbreak investigations are incomplete without the basics of epidemiology. Case definition should be made and applied. Epidemiological links between cases should be ascertained, and risk factors explored. India is not short of competence in medicine and research, but epidemiology skills, training, and field application are inadequate. Chandipura virus, encephalitis, and epidemic brain attack in IndiaAuthor's reply Full-Text PDF
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