High altitude pulmonary edema among "Amarnath Yatris"

Abstract

Background:Annual pilgrimage (Yatra) to the cave shrine of Shri Amarnath Ji’ is a holy ritual among the Hindu devotees of Lord Shiva. Located in the Himalayan Mountain Range (altitude 13,000 ft) in south Kashmir, the shrine is visited by thousands of devotees and altitude sickness is reportedly common.Materials and Methods:More than 600,000 pilgrims visited the cave shrine in 2011 and 2012 with 239 recorded deaths. Thirty one patients with suspected altitude sickness were referred from medical centers en-route the cave to Sher-i-Kashmir Institute of Medical Sciences, a tertiary-care center in capital Srinagar (5,000 ft). The clinical features and the response to treatment were recorded.Results:Thirty-one patients (all lowlanders, 19 male; age 18-60 years, median 41) had presented with acute onset breathlessness of 1-4 days (median 1.9 d) starting within 12-24 h of a rapid ascent; accompanied by cough (68%), headache (8%), dizziness and nausea (65%). Sixteen patients had associated encephalopathy. Clinical features on admission included tachypnea (n = 31), tachycardia (n = 23), bilateral chest rales (n = 29), cyanosis (n = 22) and grade 2-4 encephalopathy. Hypoxemia was demonstrable in 24 cases and bilateral infiltrates on radiologic imaging in 29. Ten patients had evidence of high-altitude cerebral edema. All patients were managed with oxygen, steroids, nifedipine, sildenafil and other supportive measures including invasive ventilation (n = 3). Three patients died due to multiorgan dysfunction.Conclusions:Altitude sickness is common among Amaranath Yatris from the plains and appropriate educational strategies should be invoked for prevention and prompt treatment.

High Altitude Pilgrimage Medicine

“…HAPE and HACE have been well documented in the Shri Amarnath Yatra in Srinagar (Koul et al, 2013), and there is also a recent case report of HAPE in a pilgrim from Kailash Manasarovar (Panthi and Basnyat, 2013).…”

“…Although co-morbidities were not taken into account in the Gosainkunda Lake studies, the studies from Srinagar (Singh et al, 2005;Ganie et al, 2012;Yatoo et al, 2012;Koul et al, 2013) reveal that pilgrims admitted to hospital have important co-morbidities such as pulmonary diseases that may increase their risk for AMS. Importantly, because many of the elderly may not be in good physical conditioning but feel obliged to do the pilgrimage, they may well be physically very exhausted, which also mimics AMS.…”

“…For 6 weeks in July and August every year, 300,000 to 600,000 pilgrims do the Shri Amarnath Yatra pilgrimage in Srinagar in India (Koul et al, 2013). There are no prospective studies of pilgrims as in Gosainkunda, but there are publications of medical problems in pilgrims admitted to hospitals in Srinagar, the largest city near the pilgrimage site which is also the state capital.…”

“…Six people died, out of which 4 were > 65 years. Most of the people who die succumb in the field (before being brought to the hospital); for example, the conservative death toll in 2011 and 2012 among 600,000 pilgrims was 239 recorded deaths amongst the pilgrims who had visited the Shri Amarnath shrine (Koul et al, 2013).…”

“…Altitude illness (Bartsch and Swenson, 2013), which comprises the relatively benign acute mountain sickness (AMS) and life-threatening high-altitude cerebral edema (HACE) and high-altitude pulmonary edema (HAPE) have been well documented in many pilgrims (Basnyat et al, 2000;Koul et al, 2013;MacInnis et al, 2013a). In addition, pilgrims also suffer from traumatic injuries on the trail and common pre-existing problems such as diabetes, peptic ulcer disease, and coronary artery disease, which may be exacerbated with poor drug compliance during travel, dietary changes, or the added stress of exertion and hypoxia at high altitude (Mir et al, 2008;Yatoo et al, 2012).…”