Atypical Reye syndrome: three cases of a problem that pediatricians should consider and remember

INTRODUCTION

Reye syndrome is a rare acquired metabolic disorder appearing almost always during childhood. Its aetiopathogenesis, although controversial, is partially understood. The classical disease is typically anticipated by a viral infection with 3-5 days of well-being before the onset of symptoms, while the biochemical explanation of the clinical picture is a mitochondrial metabolism disorder, which leads to a metabolic failure of different tissues, especially the liver. Hypothetically, an atypical response to the preceding viral infection may cause the syndrome and host genetic factors and different exogenous agents, such as toxic substances and drugs, may play a critical role in this process. Reye syndrome occurs with vomiting, liver dysfunction and acute encephalopathy, characterized by lack of inflammatory signs, but associated with increase of intracranial pressure and brain swelling. Moreover, renal and cardiac dysfunction can occur. Metabolic acidosis is always  detected, but diagnostic criteria are not specific. Therapeutic strategies are predominantly symptomatic, in order to manage the clinical and metabolic dysfunctions.

CASE REPORTS

We describe three cases of children affected by Reye syndrome with some atypical features, characterized by no intake of potentially trigger substances, transient hematological changes and dissociation between hepatic metabolic impairment, severe electroencephalographic slowdown and slightly altered neurological examination.

CONCLUSIONS

The syndrome prognosis is related to the stage of the syndrome and the rapidity and the adequateness of intensive care treatments. The analysis of the patients leads to a greater awareness of the difficult diagnosis of this not well completely known syndrome.

REYE (RAY'S) SYNDROME: A PROBLEM EVERYONE SHOULD REMEMBER

Reye syndrome is a rare but a very dangerous emergency that children and teenagers suffer. This threatening condition occurs during the treatment of fever in the clinical course of viral diseases with drugs containing acetylsalicylic acid and other salicylates. The high mortality rate from this disease is associated with the development of a rapidly progressing toxic encephalopathy and hepatic insufficiency. The etiology and pathogenesis of the Reye syndrome, despite the large number of investigations, is not clear enough. Today, special attention is paid to the development of so-called Reye-like syndromes in the context of congenital metabolic defects, although cases of the true Reye syndrome occur quite often. In spite of the long discussion among scientists, the effect of acetylsalicylic acid is an important factor of development of this pathological syndrome. Taking this fact into consideration, the use of acetylsalicylic acid by children, especially in case of colds, should be strictly controlled by a doctor and parents should be informed about possible complications, especially the development of the Reye syndrome. This issue is very urgent in countries with non-prescription antipyretics realization and a high percentage of self-treatment among patients.

Adult Reye-like syndrome associated with serologic evidence of acute parvovirus B19 infection

Reye's syndrome is an infrequently diagnosed medical condition affecting mainly children. The etiology, epidemiology and natural history of Reye's syndrome have been cloudily written in footnotes of medical books and exotic papers since the initial description in early 1950s. We report here a case of adult Reye's syndrome associated with serologic evidence of parvovirus B19 infection.

[The Reye syndrome]

The Reye syndrome is a complex disease that remains little-known despite its severity. It can occur in children of all ages, and is often fatal, while surviving children often display neurological damage. The therapy is symptomatic and supportive. The diagnosis of Reye's syndrome is not straightforward, as the symptoms are very diverse. The causes of the disease are moreover still unclear, and, after many years of discussion and research, it can still not be proved irrefutably whether administration of acetylsalicylic acid to children suffering from viral infections is a factor in the development of Reye's syndrome.

[Reye syndrome and Reye-like syndrome]

Reye syndrome (RS) is an acute metabolic encephalopathy and hepatopathy affecting children and adolescents. Outbreaks of RS were common in United States until the early 1980s. However, after the abolition of salicylate (aspirin) therapy for infectious diseases such as influenza or varicella in patients under 18 years of age the incidence decreased. Now classical RS is rare and RS is considered a secondary mitochondrial disease. Reye-like syndrome (RLS), resulting from congenital errors of mitochondrial fatty oxidation, especially medium-chain acyl-CoA dehydrogenase deficiency, has increased due to progress in diagnostic techniques and methods after 1990. Diagnostic differentiation between RS and RLS is difficult because the end results of mitochondrial dysfunction in RS and RLS may be similar.

[Reye's syndrome. Description of a case focused on the patient's epileptic seizures]

INTRODUCTION

Reye's syndrome is an acute disease characterised by encephalopathy and fatty degeneration of the liver that occurs almost exclusively in children. It can cause the death of the patient in up to a third of all cases, generally due to severe cerebral oedema. The aetiopathogenesis of this condition is uncertain and is usually preceded by a viral infection, generally from the influenza or varicella virus. Some studies have shown a strong epidemiological association between the ingestion of acetylsalicylic acid (ASA) during the viral infection and development of Reye's syndrome.

CASE REPORT

We describe the case of a 20-month-old female who developed Reye's syndrome within the context of a viral infection and the ingestion of ASA. A hepatic biopsy study is appropriate in this syndrome. The patient presented a non-convulsive status during the acute phase and at one year developed Lennox-Gastaut syndrome. She died from pneumonia at the age of 18 years.

CONCLUSIONS

In all patients with clinical features that suggest Reye's syndrome, inborn errors of metabolism that can mimic it must be precluded. Although the incidence of this syndrome has gone down considerably in recent years, it is important to keep it in mind as an early and aggressive diagnosis and treatment of cerebral hypertension will reduce the mortality rate and the sequelae.

Reye syndrome: a case report with review of literature

Here we describe a case of Reye syndrome diagnosed at postmortem liver biopsy of a three-year old girl who presented with vomiting, low grade fever for three days and loss of consciousness for 18 hours. Clinically, the differential diagnoses were meningitis, encephalitis and septicemia. No history of past illness or any drug ingestion including aspirin were present. Laboratory investigations indicated a diagnosis of Reye syndrome. The child was given supportive treatment but died after two days of admission and postmortem needle-biopsy of the liver showed microvesicular steatosis consistent with Reye syndrome.

[Adaptation of Biomerieux enzymatic UV ammonia on Konelab analysers]

INTRODUCTION

Circulating ammonia in normal patients is relatively low, despite the fact that ammonia is continually produced from endogenous amino acid metabolism. The physiopathological interest of plasmatic ammonia determination lies primarily in its relationships to hepatic insufficiency (cirrhotic or neoplasic), or the diagnosis and the forecast of the Reye's syndrome.

OBJECTS

This study describes an evaluation of plasmatic ammonia determination by the UV end point enzymatic method using GLDH on KONELAB(TM) analyzers.

METHODS

The glutamate dehydrogenase (GLDH : EC.1.4.1.3) catalyses the reducing amination of alpha-cetoglutarate in the presence of NH(4)(+) and of NADPH, H(+) to form glutamate and NADP(+). The reduction of NADPH,H(+)'s concentration, directly proportional to ammonia rates, is evaluated at 340 nm. All the conditions were met to optimize the method, while covering a satisfying field of measurement.

RESULTS AND COMMENTS

The evaluation of the modified method showed a good precision (repeatability: CV < 4 %; interserial reproducibility: CV from 2.01 to 2.93 %; Intraserial reproducibility: CV equal to 0.67%) and a very good accuracy. The field of measurement extends from 27 to 250 micromol/L, with a limit of detection (L(D)) lowered to 0.325 micromol/L.

CONCLUSION

The adapted technique is simple, fast, inexpensive and especially automatizable. It is in addition reliable and chiefly more sensitive, adapting particularly to the determination of plasmatic ammonia in urgency as in routine within our laboratory.

A case of Reye syndrome with rotavirus infection accompanied with high cytokines

We report on a 23-month-old boy with a rare complication of rotavirus gastroenteritis. He was diagnosed as acute encephalopathy with DIC accompanied with high levels of cytokines. The liver pathology also revealed mild infiltration and fatty changes. He was suspected to be suffering from a cytokine storm followed by Reye syndrome.

Duodenal perforation: an interesting case report

We describe a young child presenting with vomiting and altered neurological status. An incidental finding of pneumoperitoneum on abdominal X-ray led to laparotomy and the discovery of a duodenal perforation. We describe the difficulties in making the diagnosis of duodenal perforation in children and some of the factors that led to the delay in diagnosis in this case.

Sudden unexpected death of a 17-year-old male infected with the influenza virus

We report a case of sudden unexpected death in a 17-year-old male student showing similar clinical background and pathological findings to Reye's syndrome. He was found following cardio-pulmonary arrest in his bed, and was immediately transferred to a hospital. However, resuscitation was not successful. He had a history of high fever of 38.3 degrees C, general malaise, myalgia, and gastrointestinal discomfort for the 2 days prior to his death, and an injection of pylazolon and medication comprising anti-emetics had been administered the day before he died. His biochemical findings showed almost normal levels of transaminase, electrolytes and protein fractions at the emergency room, but blood from the heart at autopsy revealed a high titer of the influenza A virus. Macroscopically, in addition to considerable fatty metamorphosis of the liver, concentric hypertrophy of the left ventricle, muscular bridge of left anterior descending artery, moderate coronary atherosclerosis, and mild downward displacement of the septal leaflet of the tricuspid valve were noted in the heart. Although panlobular microvesicular fatty infiltration of the liver was seen, deposition of lipid droplets was detected only in hepatocytes by frozen section of several organs. Serial sectioning of the epicardial coronary arteries showed about 50% stenosis at the distal site of the left circumflex artery, and diffuse interstitial fibrosis was evident in the bilateral ventricle and this was relatively severe for his age. In addition, the atrioventricular (AV) node artery showed severe narrowing just before entering the AV node, and downward displacement of the AV node with longitudinal elongation was also remarkable. We consider that the cause of death was sudden cardiac death rather than Reye's syndrome (RS), and that an arrhythmogenic event due to some preceding unusual cardiac lesions may have become overt due to the influenza infection and/or some related disorders. The present case would seem to suggest that a postmortem diagnosis of RS should be determined very carefully in cases of sudden death, even if the general circumstances would seem to be consistent with RS.

[Influenza encephalopathy, related disorders and differential diagnosis]

Influenza encephalopathy and related disorders such as Reye's syndrome, acute necrotizing encephalopathy and acute hemorrhagic encephalopathy are still undefined clinical entities because the pathophysiology is not clearly established. Even Reye's syndrome which has been extensively studied during the last two decades, its real picture has not been well established. Moreover, Reye's syndrome is going to disappear just like Ekiri syndrome. Acute necrotizing encephalopathy and acute hemorrhagic encephalopathy need further investigation to be recognized as single clinico-pathological entity because decreased cerebral blood flow is closely linked with brain edema including basal ganglia lesion and hepato-renal dysfunction.

Reye's syndrome: down but not out

Reye's syndrome presents as acute central nervous system and liver dysfunction in children. Its incidence has seen a sharp decline in parallel with the decline in the use of aspirin in the pediatric age group. This report describes a patient with Reye's syndrome and serves as a reminder for health professionals to continue to discourage the use of aspirin for the treatment of viral infections.

Serum free carnitine in medium chain acyl-CoA dehydrogenase deficiency

Medium chain acyl-CoA dehydrogenase (MCAD) deficiency is the most common disorder of fatty acid beta-oxidation and presents acutely with hypoglycemia, or a Reye-like illness with low free carnitine, often provoked by an infection or an excessive period of fasting. After acute attack these children are for the most time asymptomatic and may have normal plasma free carnitine concentrations. We observed a regularity in time course of serum free carnitine concentration during two attacks of Reye-like illness in patient with MCAD deficiency. Molecular investigation confirmed that the patient was homozygote for A985G mutation. Free carnitine was measured by enzymatic UV-test. First attack of severe hypoglycemia and Reye-like symptoms started at the age of 15 months and the second at the age of 25 months. In both episodes, treatment with intravenous glucose was given immediately, but without carnitine supplementation. Between the attacks patient was on a normal diet. In both attacks, low serum free carnitine concentration from the time of acute attack continually decreased for up to 8-13 days and then normalized at about 25 days after attack. We think that the time course of serum free carnitine may help in knowledge about carnitine depletion in MCAD deficiency. This is the first observation of this pattern during an acute attack and needs to be confirmed by other patients with MCAD deficiency. (Fig. 2, Ref. 7.).

Neonatal presentation of ventricular tachycardia and a Reye-like syndrome episode associated with disturbed mitochondrial energy metabolism

BACKGROUND

Hyperammonemia, hypoglycemia, hepatopathy, and ventricular tachycardia are common presenting features of carnitine-acylcarnitine translocase deficiency (Mendelian Inheritance in Man database: *212138), a mitochondrial fatty acid oxidation disorder with a lethal prognosis. These features have not been identified as the presenting features of mitochondrial cytopathy in the neonatal period.

CASE PRESENTATION

We describe an atypical presentation of mitochondrial cytopathy in a 2 day-old neonate. She presented with a Reye-like syndrome episode, premature ventricular contractions and ventricular tachycardia. Initial laboratory evaluation exhibited a large amount of 3-methylglutaconic acid on urine organic acid analysis, mild orotic aciduria and a nonspecific abnormal acylcarnitine profile. The evaluation for carnitine-acylcarnitine translocase deficiency and other fatty acid oxidation disorders was negative. The patient later developed a hypertrophic cardiomyopathy and continued to be affected by recurrent Reye-like syndrome episodes triggered by infections. A muscle biopsy exhibited signs of a mitochondrial cytopathy. During the course of her disease, her Reye-like syndrome episodes have subsided; however, cardiomyopathy has persisted along with fatigue and exercise intolerance.

CONCLUSIONS

This case illustrates that, in the neonatal period, hyperammonemia and ventricular tachycardia may be the presenting features of a lethal carnitine-acylcarnitine translocase deficiency or of a mitochondrial cytopathy, associated with a milder clinical course. This association broadens the spectrum of presenting phenotypes observed in patients with disturbed mitochondrial energy metabolism. Also, the presence of 3-methylglutaconic aciduria suggests mitochondrial dysfunction and mild orotic aciduria could potentially be used as a marker of mitochondrial disease.

[Refractory epilepsy status in Reye's syndrome in an adult. A case report]

INTRODUCTION

Reye s syndrome (RS) is a potentially fatal disease described in 1963 by Reye, Morgan and Baral as an acute encephalopathy associated with a lipid degeneration of the liver. It affects children of all ages, with a peak incidence between 5 and 15 years old, but on rare occasions it can also affect adults. Its aetiology is not known, but is has been linked with viral infections and with the ingestion of salicylates. Its occurrence in adults is not at all frequent and only 27 cases have been recorded in the literature.

CASE REPORT

We report the case of a 33 year old primiparous patient who, during lactation, began suffering from epilepsy and a lowered level consciousness in the course of an infection of the pharynx and tonsils, and died on the 12th day after admission to the ICU. Anamnesis revealed she had taken ASA for the first time in her life, which guided diagnosis, and this was confirmed post mortem in the anatomopathological examination.

CONCLUSION

RS in adults occurs only rarely but should be a part of the differentiating diagnosis of any encephalopathy of unknown origin and especially of the epileptic status of an adult, above all if there is a history of ingestion of salicylates, previous viral infection and vomiting.

[Microvesicular steatosis]

BACKGROUND

"Bright" liver at ultrasonography predicts fatty liver.

AIM

To assess prevalence and predictors of a bright liver.

METHODS

Prevalence arm--Prospective collection of records of unselected patients undergoing liver ultrasound. Protocol arm--A sample of patients with bright liver underwent routine laboratory investigations, liver tests, HBsAg and anti-HCV.

RESULTS

No difference was found in mean values of fasting plasma glucose, LDL cholesterol, total bilirubin, GOT, GPT, AP, GGT, and serum bile acids or in the prevalence of serum HBsAg and anti-HCV in bright liver vs control groups. Univariate analysis showed body mass index, age, total cholesterol triglycerides, albumin, HDL cholesterol to be significantly.

CONCLUSIONS

Roughly 20% of patients undergoing US for routine clinical practice will have a bright liver and levels are the independent predictors of a bright liver.

Pontocerebellar hypoplasia type 2 and Reye-like syndrome

Pontocerebellar hypoplasia is an autosomal recessive syndrome with onset during the fetal period. Two subtypes of pontocerebellar hypoplasia have been described on the basis of clinical and neuropathologic criteria. Pontocerebellar hypoplasia type 2 is characterized by progressive microcephaly, early onset of extrapyramidal dyskinesia, and near absence of motor and cognitive development, without signs of either spinal or peripheral involvement. We report a clinical observation of a patient with pontocerebellar hypoplasia type 2, a 3-year-old girl with progressive microcephaly, dystonic limb movements, and absence of motor and cognitive development. Cranial magnetic resonance imaging revealed pontocerebellar hypoplasia. At the age of 2 years, she suffered a Reye-like syndrome that worsened her condition. Differential diagnosis was established with intrauterine injuries, other malformative syndromes, and neurodegenerative or neurometabolic disorders, which can be associated with cerebellar hypoplasia.

[Reye's syndrome: the death of a syndrome? (Or death by a syndrome?)]

Reye syndrome is characterized by acute encephalopathy and fatty degeneration of the liver almost exclusively in children. The onset is heralded by profuse vomiting and varying neurologic impairment from irritability to coma, decerebration and death. The encephalopathy must be associated with a greater increase in the levels of ammonia, or alanine amino-transferase and aspartate amino-transferase in serum; and with a fatty metamorphosis of the liver diagnosed by biopsy or at autopsy. The only characteristic universally accepted as diagnostic are the specific mithocondrial changes in the liver-biopsy specimen. Larger studies confirmed the association of aspirin with RS. The CDC of Atlanta cautioned physician and parents and a dramatic decline in case began at that time. Classic Reye syndrome is now so rare in the USA that when an apparent case is encountered in a child who has not taken aspirin, other diagnoses should be considered. After a brief survey of RS relative lack of specificity of case definition and of the polyhedric etiopathogenetic moments, the A. on the personal experience, point: a) the biological unicity of the man and the necessary coexistence of "constitutional" factors (metabolic and/or endocrine, and/or immunitary factors, the later almost never investigated), toxic, and infectious factors for the syndrome's deflagration; b) some aspects of the continued existence of therapeutic and diagnostic problems: the aspirin and/or salicilate use and the pharmacogenetic; the continued existence of other, generally similar conditions, such the drug and other known and unknown toxic mithocondrial factors that provoke this unusual response to common infections; and the inborn errors of metabolism; c) some practical aspects of diagnostic and therapeutic approach.

Reye's syndrome in an adult: a case report

Reye's syndrome (RS), a condition characterized by encephalopathy and fatty liver, is associated with aspirin use and carries a poor prognosis. The majority of patients with RS are children and adolescents. We report a case of RS in an adult.

Reye syndrome revisited: a descriptive term covering a group of heterogeneous disorders

Reye syndrome, characterised by the combination of liver disease and noninflammatory encephalopathy, is a non-specific clinicopathological entity and a descriptive term covering a group of heterogeneous disorders. Nowadays, some of these patients are diagnosed more correctly as having infectious, metabolic, toxic or other disease. The non-specific case definition implies that the epidemiological studies suggesting a link with acetylsalicylic acid have been performed on a heterogeneous group of children, whereby the value of these studies and their ensuing hypothesis is weakened. Moreover, a detailed analysis of the epidemiological surveys of the Centers for Disease Control, the Yale study and of the British risk factor study provides evidence that not only the use of acetylsalicylic acid but also that of phenothiazines and other anti-emetics is significantly greater in Reye syndrome cases than in controls. As to the decline of Reye syndrome, recent literature data reveal that this is related to more accurate modern diagnosis of infectious, metabolic or toxic disease, reducing the percentage of idiopathic or true cases of Reye syndrome.

CONCLUSION

Reye syndrome is a non-specific descriptive term covering a group of heterogeneous disorders. Moreover, not only the use of acetylsalicylic acid but also of antiemetics is statistically significant in Reye syndrome cases. Both facts weaken the validity of the epidemiological surveys suggesting a link with acetylsalicylic acid.

Hereditary fructose intolerance presenting as Reye's-like syndrome: report of one case

Hereditary fructose intolerance (HFI) is an autosomal recessive disease caused by catalytic deficiency of aldolase B (fructose-1, 6-bisphosphate aldolase). Herein we report on a case of hereditary fructose intolerance with initial presentation of episodic unconsciousness, seizure, hypoglycemia, hepatomegaly, and abnormal liver function since the patient was 11 months old. She was diagnosed as Reye's-like syndrome according to a liver biopsy done at 20 months of age. As she grew up, cold sweating, abdominal pain or gastrointestinal discomfort shortly after the intake of fruits was noted and she developed an aversion to fruits, vegetables and sweet-tasting foods. At 9 years of age, a fructose tolerance test signified a positive result that induced hypoglycemia, transient hypophosphatemia, hyperuricaemia, elevation of serum magnesium, and accumulation of lactic acid. Appropriate dietary management and precautions were recommended. The patient has been symptom-free and exhibited normal growth and development when followed up to 12 years of age.

Metabolic disorders mimicking Reye's syndrome

BACKGROUND

Several metabolic disorders such as encephalopathy and hepatic dysfunction have been described as Reye's-like syndrome because they present with similar clinical manifestations that mimic Reye's syndrome. We performed a retrospective study to explore the underlying metabolic etiologies of Reye's-like syndrome in patients treated at National Taiwan University Hospital.

METHODS

From January 1991 to June 1998, 19 children with a syndrome fitting the Reye's-like syndrome description were identified for study. Urine organic acid analysis, plasma amino acid analysis, liver pathology, and skin fibroblast enzyme assays were studied during the acute stage of illness.

RESULTS

The etiologies of patients' syndromes included urea cycle disorders (n = 7), glycogen storage disease type Ia (4), primary carnitine deficiency (2), hereditary fructose intolerance (1), methylmalonic acidemia (2), and 3-hydroxy-3-methylglutaric acidemia (1). Fatty acid oxidation defects were suspected in the remaining two cases.

CONCLUSIONS

A significant number of patients who present with Reye's-like syndrome have an underlying inherited metabolic disorder. In patients with Reye's-like syndrome, an accurate diagnosis is essential to ensure normal growth and development and to prevent recurrence of the condition.

[Reye's syndrome--a severe complication of salicylate therapy]

Clinical and experimental data are reviewed on the Reye's syndrome--a heavy complication accompanying the therapy of viral infections in children by salicylates. Disorders in the bioenergetics of fatty acid oxidation and ammonia utilization are considered in the context of clinical manifestations of the Reye's syndrome.