At least 53 children have died in Muzaffarpur, Bihar, in northern India, from a brain disease thought to be linked to lychee fruit, while dozens more have been hospitalized.

Acute Encephalitis Syndrome (AES), known as Chamki Bukhar in India, is a brain disease that has been linked to a toxic substance in lychee fruit. The symptoms include fever, vomiting and unconsciousness.

More than 40 children are being treated in intensive care with similar symptoms to those who died in the district, which is home to the largest lychee cultivation area in India.

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After 150 people died of the illness in that district in 2014, Lancet Global Health research found a connection between lychee consumption and AES deaths. The fruit contains unusual amino acids that can disrupt gluconeogenesis depending on its ripeness, the amount eaten and the state of nourishment of the children.

“It generally hits those children who go to sleep with an empty stomach at night and eat lychees fallen on the ground,” Bihar chief minister Nitish Kumar explained, The Hindu reports.

Since 2010, 398 children have died in Muzaffarpur due to suspected AES.

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