Sago haemolytic disease: towards understanding a novel food-borne toxicosis

Sago haemolytic disease is a rare but sometimes fatal disease found primarily in the coastal regions of Papua New Guinea and among groups in which sago is a primary source of carbohydrate. It has been known since 1961 and fungi consistently have been suspected of being involved. Investigations carried out on stored sago and samples recovered from poisoning episodes have failed to indicate the consistent presence of mycotoxins. However, fungi (especially Aspergillus, Fusarium, Penicillium, Trichoderma) with strong haemolytic activity have been associated with sago, particularly when stored in open-weave baskets and sago-leaf-wrapped bundles. The haemolytic activity has been attributed to fatty acids (principally oleic, palmitic, linoleic) contained primarily in the fungal hyphae. It is hypothesized that when these acids are released through hyphal breakdown during digestion and are present in individuals with a low serum albumin level, free fatty acid excess occurs resulting in red cell membrane destruction and intravascular haemolysis. In extreme cases, blood transfusion is required. Methods of storage providing high levels of access to oxygen favour the development of fungi: eg, leaf-encased bundles and open-weave storage favour growth over that seen in starch stored under water, such as in earthen vessels. Ensuring storage does not exceed 3-4 weeks, encouraging anaerobic conditions of the starch and maintaining protein nutrition in communities where sago is relied upon should alleviate outbreak episodes.