[4] Abdominal discomfort begins two to six hours after eating unripe ackee fruit, followed by sudden onset vomiting.
First, it interferes with the transport of long-chain fatty acids into the mitochondria by forming ester linkages with carnitine and coenzyme A (CoA).
[3] Inhibition of beta-oxidation of fatty acids, however, also depletes nicotinamide adenine dinucleotide (NADH) and acetyl CoA—the latter an activator of pyruvate carboxylase—inhibiting gluconeogenesis.
[5][6] A similar outbreak of lethal hypoglycemic encephalopathy has been linked to the consumption of lychee fruit in Muzaffarpur, India.
[7] The disease appears in the ER episode "Great Expectations", where the symptoms are recognised by Dr. Mallucci who, it is later revealed, attended medical school in Grenada.