Hypoglycemic Toxins and Enteroviruses as Causes of Outbreaks of Acute Encephalitis-Like Syndrome in Children, Bac Giang Province, Northern Vietnam

Emerg Infect Dis. 2018 Aug;24(8):1435-1443. doi: 10.3201/eid2408.171004.


We investigated the cause of seasonal outbreaks of pediatric acute encephalitis-like syndrome associated with litchi harvests (May-July) in northern Vietnam since 2008. Nineteen cerebrospinal fluid samples were positive for human enterovirus B, and 8 blood samples were positive for hypoglycemic toxins present in litchi fruits. Patients who were positive for hypoglycemic toxins had shorter median times between disease onset and admission, more reports of seizures, more reports of hypoglycemia (glucose level <3 mmol/L), lower median numbers of leukocytes in cerebrospinal fluid, and higher median serum levels of alanine aminotransferase and aspartate transaminase than did patients who were positive for enteroviruses. We suggest that children with rapidly progressing acute encephalitis-like syndrome at the time of the litchi harvest have intoxication caused by hypoglycemic toxins, rather than viral encephalitis, as previously suspected. These children should be urgently treated for life-threatening hypoglycemia.

Keywords: Bac Giang Province; Vietnam; acute encephalitis syndrome; acute encephalitis-like syndrome; children; encephalitis; enteroviruses; hypoglycemia; hypoglycemic toxins; hypoglycins; litchi; litchi cultivation; meningitis/encephalitis; methylenecyclopropylglycine; outbreaks; viruses.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute Febrile Encephalopathy / epidemiology*
  • Acute Febrile Encephalopathy / etiology*
  • Child
  • Child, Preschool
  • Enterovirus Infections / complications*
  • Enterovirus Infections / epidemiology
  • Enterovirus*
  • Female
  • Humans
  • Infant
  • Male
  • Retrospective Studies
  • Seasons
  • Vietnam / epidemiology