Acute mountain sickness (AMS) in a Nepali pilgrim after rapid ascent to a sacred lake (4380 m) in the Himalayas

Abstract

A 55-year-old female Nepali pilgrim presented to the Himalayan Rescue Association Temporary Health Camp near the sacred Gosainkund Lake (4380 m) north of Kathmandu, Nepal, with a complaint of severe headache, vomiting and light-headedness. She was diagnosed with severe acute mountain sickness. Intramuscular dexamethasone was administered. Paracetamol (acetaminophen in the USA and Canada) and ondansetron were given as supportive management for headache and nausea. Arrangements were made to have her carried down by a porter immediately. After the descent, all her symptoms resolved. High-altitude pilgrims are a more vulnerable group than trekkers and mountaineers. Pilgrims generally have a rapid ascent profile, have low awareness of altitude illness and are strongly motivated to gain religious merit by completing the pilgrimage. As a result, there is a high incidence of altitude illness among pilgrims travelling to high-altitude pilgrimage sites.

Case presentation

A 55-year-old female Nepali pilgrim with a medical history of diabetes and hypertension presented to the Himalayan Rescue Association (HRA) Temporary Health Camp near the sacred Gosainkund Lake (4380 m) with complaints of severe headache, vomiting and light-headedness. She began her pilgrimage from Kathmandu (1300 m) and arrived at Dhunche (1950 m), the starting point of her trek, by bus for several hours. She reached Chandanbari (3330 m, also known as Singh Gompa) by late afternoon. She started having a mild headache at Chandanbari, so she took a 500 mg paracetamol tablet and rested for a while. She continued her journey and reached Laurebina (3910 m) later that evening. There she was nauseated and could not finish her dinner. She had poor sleep and woke up several times throughout the night. The next morning, disregarding her symptoms she ascended further towards her destination, the sacred lake. Her progress on the second day was very slow compared with her rate of ascent on the first day. After arriving at Buddhamandir (4200 m) in the afternoon, her headache worsened. She was also light-headed and could no longer walk as she was extremely tired. Still, her determination to complete her pilgrimage persisted, so her family arranged for a horse to carry her. She finally reached Gosainkund Lake (4380 m) on horseback in the evening of the second day of her trek.

After reaching her destination, she was brought to the HRA Temporary Health Camp promptly by her family members. She complained of severe frontal headache and light-headedness. She had vomited twice after reaching the destination. On examination, her temperature was 36°C, pulse was 110/min, respiratory rate was 26/min and blood pressure was 150/92 mm Hg, and she had an oxygen saturation of 88% on room air, which can be considered normal at an altitude of 4380 m. Lung sounds were clear bilaterally and heart sounds were normal. There were no focal motor or sensory neurological deficits. Cranial nerves II–XII were intact. Finger to nose test was normal. Tandem gait test showed no signs of ataxia. We diagnosed her with severe acute mountain sickness (AMS). The absence of altered mental status and no signs of ataxia suggested she did not have high-altitude cerebral oedema (HACE) at that time.

The patient received one dose of intramuscular 4 mg dexamethasone. Two tablets of 500 mg paracetamol by mouth and one tablet of 4 mg ondansetron by mouth were given for symptomatic management of headache and nausea. We recommended that the patient and her family members descend immediately. Her family members were also treated for mild to moderate AMS. The patient and her family members were counselled regarding the risk of altitude illness, especially in the setting of rapid ascent. She was carried by a porter and rushed down immediately. Despite the heavy rainfall and bad weather conditions, they descended to Lauribena (3910 m) and slept the night there, and arrived at Chandanbari (3330 m) the next day. She had no headache nor any other symptoms at 3330 m as reported by her family.

Global health problem list

1. There is a high incidence of altitude illness among Nepali pilgrims travelling to high altitude.

2. There is a very rapid rate of ascent among Nepali pilgrims travelling to high altitude.

3. Low awareness and misconception about altitude illness are common among Nepali pilgrims.

4. Pilgrims have a strong determination to complete their pilgrimage to gain religious merit, thus making them susceptible to altitude illness.

Global health problem analysis

High-altitude illness is the general term for AMS, HACE and high-altitude pulmonary oedema (HAPE). High-altitude illness usually occurs above 2500 m.¹ AMS is characterised by symptoms of headache, nausea, fatigue and dizziness, usually without any physical findings. AMS typically develops 6–12 hours after ascent to high altitude. The diagnosis of AMS requires the presence of headache and at least one of the other symptoms mentioned above. HACE is an encephalopathy with physical findings of ataxia, altered mental status or both due to cerebral involvement, but usually lacks focal neurological deficits. HAPE is a pulmonary form of high-altitude illness with symptoms of shortness of breath, extreme fatigue and cough, with physical findings of cyanosis, hypoxia and crackles.^{2 3} The important high-altitude illness-specific problems faced by the pilgrims are AMS, HAPE and HACE.^{4 5}

Pilgrims travel to high-altitude pilgrimage destinations to worship their deities and to take holy dips in sacred lakes with the religious belief of washing away their sins. There are several high-altitude pilgrimage sites in South Asia which are annually visited by millions of pilgrims. The important ones are Kailash Manasarovar in Tibet (>5000 m, estimated pilgrims annually 40 000); Gosainkund (4380 m, estimated pilgrims annually 10 000–20 000), Muktinath (3700 m, estimated pilgrims annually 30 000), Damodhar Kunda (4800 m, no data available on annual estimated pilgrims), Dudh Kunda (4500 m, no data available on annual estimated pilgrims) and Tilicho Lake (4900 m, no data available on annual estimated pilgrims) in Nepal; and Sri Amarnath (3800 m, estimated pilgrims annually 400 000–600 000), Kedarnath (3500 m, estimated pilgrims annually 600 000) and Badrinath (3100 m, estimated pilgrims annually 100 000) in India.⁶

High incidence of altitude illness among Nepali pilgrims travelling to high altitude

High-altitude pilgrims are different from trekkers and mountaineers. Pilgrims usually are less aware of altitude illness and are generally underprepared for the high-altitude journey.^{6 7} The cross-sectional study done at Gosainkund in 1998 had shown the incidence of AMS in randomly chosen pilgrims to be 68%.⁸ Another large cohort study done in 2013 in pilgrims at Gosainkund showed the incidence of AMS to be 34%.⁹ The significant difference in the incidence rate between the above two studies could be related to the design of the study, cross-sectional versus longitudinal, respectively. A study done in 2014 at Gosainkund showed the incidence of AMS to be 29% among patients attending the HRA Temporary Health Camp.⁴ All the above studies noted the rapid rate of ascent, which was around 2 days in the majority of pilgrims reaching Gosainkund Lake. The important reasons for such persistently high incidence of altitude illness among pilgrims in Nepal are the rapid rate of ascent and lack of knowledge about altitude illness and preventive measures.^{4 9}

The rapid rate of ascent among Nepali pilgrims travelling to high altitude

According to the Wilderness Medical Society practice guidelines for the prevention and treatment of acute altitude illness, individuals ascending to more than 3500 m in 1 day are considered to be at high risk of altitude illness. Also individuals with a history of AMS and ascending to 2800 m or more in 1 day or greater than 500 m ascent in 1 day above 3500 m are considered to be at high risk of altitude illness.¹⁰ Rapid ascent does not provide adequate time for acclimatisation to high altitude. At Gosainkund Lake the majority of pilgrims have a rapid rate of ascent, averaging about 2 days from the starting point, from 1950 m to 4380 m.^{8 9} Unlike trekkers whose main purpose of travelling to high altitude is to enjoy scenic beauty, the motivation of the majority of pilgrims for high-altitude travel is to gain religious merit by completing a pilgrimage. Most pilgrims have a strong desire to reach the destination quickly and to spend minimal time at their final pilgrimage destination. There are limited accommodations and it is very expensive to buy food along the way. Apart from the religious zeal, the high cost of lodging and buying meals during pilgrimage may also contribute to rapid ascent. The majority of pilgrims at Gosainkund Lake only stay for one night.⁴ This sentiment of finishing the pilgrimage as early as possible also contributes to the rapid rate of ascent among the pilgrims. It is common to see pilgrims ascending to high-altitude pilgrimage sites on horseback after they are unable to continue the journey on foot, as our patient did. Ascending on horseback complicates the situation as the rate of ascent becomes faster. This can increase both the likelihood and severity of altitude illness.

Low awareness and misconception about altitude illness among Nepali pilgrims

Many pilgrims have the traditional belief that altitude illness is caused by the scent of the wildflowers. This mistaken belief might also contribute to the rapid ascent of pilgrims as they walk rapidly up trying to avoid the scent as much as possible.^{7 11} There is another misconception among pilgrims that using unproven traditional remedies like garlic might help prevent or cure altitude illness.^{7 9} Pharmacological prophylaxis with acetazolamide is uncommon among pilgrims. In a study conducted at Gosainkund, it was reported that about 70% of pilgrims ingested one or more remedies such as garlic, ginger and lemon with the traditional belief that it might help prevent altitude illness.⁹ The incidence of AMS was higher in pilgrims taking garlic.⁹ One of the reasons could be that the pilgrims who took garlic might have thought that garlic would be preventive against altitude illness and this belief may have resulted in a faster rate of ascent.

Strong determination among pilgrims to complete their pilgrimage to gain religious merit

Hindu pilgrims believe that by taking a dip in the sacred lake, they wash away their sins and they also gain immense religious merit. Many elderly pilgrims also have a religious belief that dying at a sacred pilgrimage site opens the stairway to heaven and takes one closer to the Gods. These beliefs prevent the majority of pilgrims from turning back even when their symptoms get worse. The practice of religious fasting is prevalent among pilgrims. This can result in dehydration and electrolyte imbalances. Although there is no clear evidence that dehydration can directly contribute to AMS, some studies have suggested that there is an increased incidence of AMS in people with poor fluid intake during trekking.^{12 13} Strong religious beliefs result in many pilgrims being vulnerable to altitude illness during their pilgrimage.^{7 11}

What can be done?

High-altitude pilgrims are very susceptible to altitude illness. An effort to increase awareness of altitude illness among Nepali pilgrims is crucial to reduce the incidence of altitude illness. The HRA is a non-profit organisation that has been working in the Himalayas of Nepal for decades, increasing awareness and organising interactive awareness programmes and temporary medical camp near Gosainkund Lake during the Janai Purnima festival every year for over 20 years.^{6 7}

The Ministry of Health and Population of Nepal should come up with standard policies to implement pretravel evaluation and counselling by medical doctors and health workers before the pilgrimage. The Ministry should collaborate with the organisation like the HRA. Collaboration should aim to provide medical doctors and health workers with experience in high altitude medicine for teaching the pilgrims on the complications of high-altitude travel and the measures to prevent them before pilgrimage. Most pilgrims are generally underprepared for their high-altitude journey, and it is not surprising to find many pilgrims on the way to Gosainkund Lake in Nepal travelling in slippers.⁷ Safety measures like proper clothing and shoes during pilgrimage should also be taught as part of pretravel counselling. Pretravel evaluation and counselling would help to increase awareness of altitude illness and its preventive measures. This may help to decrease the incidence of altitude illness among Nepali pilgrims.

The rate of ascent among pilgrims should be as recommended by the Wilderness Medical Society practice guidelines for the prevention and treatment of acute altitude illness.¹⁰ Increasing public awareness on the risks of rapid ascent and the importance of immediate descent if symptoms worsen or persist should be given the highest priority. Prophylactic use of acetazolamide may be another feasible option for decreasing the incidence of altitude illness in high-altitude pilgrims.^{6 14} If the culture of rapid rate of ascent among pilgrims is not corrected, the prophylactic use of acetazolamide may not be beneficial. There is conflicting evidence from previous studies on the usefulness of acetazolamide during rapid ascent situation. A study done at Mt Rainier showed that acetazolamide was effective in preventing AMS in climbers during rapid ascent.¹⁵ But the two studies conducted at Mt Kilimanjaro showed that during rapid ascent, acetazolamide may not be effective in preventing AMS.^{16 17} There are no studies done on pilgrims to see whether acetazolamide would be effective in preventing altitude illness during rapid ascent. Increasing awareness among local health professionals on the high incidence of altitude illness in pilgrims is also an important step. This measure will help to implement pretravel counselling and the use of prophylactic medication when appropriate and may decrease the incidence of altitude illness among Nepali pilgrims overall.

Patient’s perspective.

I’m the daughter of the patient. My family and I had traveled to sacred Gosaikunda Lake during which we all had altitude illness, especially my mother suffered from the severe altitude illness. We thought altitude illness was only headache and did not know about the seriousness of the disease. We would like to thank the doctors and staffs from HRA who took care of us in their medical camp at Gosaikunda Lake. We learned and realised about the altitude illness, its preventive measures, and most notably the importance of slow and gradual ascent to high altitude. We will spread awareness regarding altitude illness to friends, relatives, and anyone that we come across in future who has the plan to travel to high altitude destinations.

Learning points.

• High-altitude illness is a preventable disease.

• Increasing awareness on altitude illness and preventive measures among Nepali pilgrims travelling to high-altitude pilgrimage sites can help to decrease the incidence of altitude illness.

• The rapid rate of ascent among Nepali pilgrims travelling to high altitude is one of the most important factors for increased incidence of altitude illness.

• Preventing rapid ascent can significantly decrease the incidence of altitude illness among Nepali pilgrims.

• Annually thousands of Nepali pilgrims travel to various high-altitude pilgrimage sites in Nepal.

• Educating local health professionals on the high incidence of altitude illness among Nepali pilgrims is also an important step.

• At present most local health professionals possess very basic knowledge about altitude illness, especially in the pilgrim population.

• Increased awareness of local health professionals may help to increase pretravel evaluation and counselling of pilgrims, and this may help to decrease the incidence of altitude illness among Nepali pilgrims overall.