NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.

Reye Syndrome
Authors

Jennifer Chapman1; Justin K. Arnold2.

Affiliations
1
Lahey Health Systems
2
University of South Florida

Last Update: November 22, 2019.

Introduction
Reye syndrome is a rare and potentially fatal pediatric illness defined as acute noninflammatory
encephalopathy with fatty liver failure. Australian pathologist R.D.K. Reye first described this
syndrome in 1963. National surveillance of Reye syndrome began in the United States in
the early 1970s and led to strict warnings regarding aspirin use in children. Reye syndrome
typically presents in children as vomiting and confusion with rapid progression to coma and
death. This syndrome often begins in the days following recovery from a viral illness during
which aspirin was administered. Inborn errors of metabolism (especially fatty acid metabolism),
medication reactions and toxins may also predispose or cause the development of Reye
syndrome. This diagnosis is based on clinical signs as well as laboratory testing. However, there
is no test specific to Reye syndrome.[1][2]

Etiology
Reye syndrome is most commonly precipitated by viral pathogens such as influenza A and B as
well as varicella. Center for Disease Control and Prevention (CDC) surveillance data between
1980 and 1997 found that cases of Reye syndrome were preceded by influenza infection 73%,
varicella infection 21%, and gastroenteritis infections 14% of the time. Serum salicylate
concentrations were detectable in 82% of cases. Less commonly associated viral associations are
seen with coxsackie, parainfluenza, Epstein-Barr (EBV), cytomegalovirus (CMV), adenovirus
and hepatitis. Bacterial pathogens such as Chlamydia, Bordetella pertussis, Mycoplasma,
and Shigella have also been associated with the development of Reye syndrome. Epidemiologic
studies found a link between use of salicylate and development of Reye syndrome. While less
than 0.1% of children who took aspirin developed Reye syndrome, more than 80% of children
diagnosed with Reye syndrome had taken aspirin in the preceding 3 weeks. This data led to
recommendations against the use of aspirin in children in 1980. The number of reported cases of
Reye syndrome fell dramatically following the widespread warnings against the use of aspirin in
children.[3][4]

Epidemiology
Reye syndrome is a rare diagnosis with fewer than 2 cases reported annually since 1994.
However, the true incidence may not be known for reporting cases to the CDC is no longer
mandated. The peak age of onset is 5 to 14 years of age; however, cases have been reported in
children less than one year of age. Gender has not been reported as a risk factor. There is
seasonal variation with the majority of cases being reported from December through April.

National surveillance of Reye syndrome began in 1973. The CDC reported 555 cases between
1979 and 1980. Between December 1980 through November 1997, the CDC reported 1207 cases
of Reye syndrome in the United States. The incidence fell from an average of 100 cases per year
in 1985 and 1986 to an average of 36 cases per year between 1987 and 1993. Incidence has
fallen off sharply since 1991 with 0.2 to 1.1 case per million reported in the United States
between 1991 and 1994.

Widespread warnings again the use of aspirin in children were issued in the United States in
1980. A sharp decline in the number of reported cases of Reye syndrome followed this issuance.
Similar patterns of incidence were observed in the United Kingdom. In 1986, the United
Kingdon warned against the use of aspirin in children under the age of 12. Following that
warning, the incidence fell from 0.63 cases per 100,000 in 1983-1984 to 0.11 cases per 100,000
in 1990 through 1991. Similar declines were also observed in France.

It should be noted that aspirin remains a mainstay of treatment for children diagnosed with
Kawasaki disease. In children who require long-term salicylate therapy, clinicians and caregivers
should remain vigilant in monitoring for signs and symptoms of Reye syndrome.[5][6]

Pathophysiology
The exact pathophysiology of Reye syndrome is not precisely known; however, it appears to
involve mitochondrial injury in the setting of a viral illness. Aspirin may cause or
perpetuate damage to cellular mitochondria resulting in inhibition of fatty-acid metabolism. The
neurologic features of Reye syndrome likely result from hepatic mitochondrial dysfunction
causing elevated ammonia levels. Hyperammonemia may induce astrocyte edema resulting in
diffuse cerebral edema and subsequent elevated intracranial pressure. Pathology studies have
revealed astrocyte edema, loss of neurons, fatty degeneration of kidneys, and a swollen and a
reduced number of mitochondria.[7]

History and Physical

A high level of suspicion based on the history of presenting illness, clinical signs and symptoms
and laboratory findings are required to make this rare diagnosis. Signs and symptoms of Reye
syndrome typically develop between 12 hours and 3 weeks after recovery from a viral illness
such as upper respiratory tract infection or gastroenteritis. The most common onset of vomiting
occurs between 3 and 6 days after a viral illness. The CDC has described clinical progression as
5 distinct stages:

Stage 1

 Persistent, copious vomiting

 Lethargy, nightmares, increased somnolence
 Confusion

Stage 2

 Stupor, disorientation, combativeness, delirium

 Hyperreflexia, positive Babinski sign, lack of appropriate response to noxious stimuli,
dilated and sluggish pupils
 Hyperventilation, tachycardia 

Stage 3

 Obtunded, comatose, decorticate rigidity

Stage 4

 Pupil dilation with minimal response to light or fixed and dilated pupils, deconjugate
gaze with caloric stimuli
 Deep coma with decerebrate rigidity

Stage 5

 Seizures
 Flaccid paralysis, absent deep tendon reflexes, no pupillary response
 Respiratory arrest
 Death

Evaluation
The CDC has defined Reye syndrome using the following criteria:

"Acute noninflammatory encephalopathy that is documented clinically by a) an alteration in

consciousness and, if available b) a record of cerebrospinal fluid (CSF) containing less than or
equal to 8 leukocytes/cu.mm or a histologic specimen demonstrating cerebral edema without
perivascular or meningeal inflammation.

Hepatopathy documented by either a) a liver biopsy or an autopsy considered to be diagnostic of

Reye syndrome or b) a threefold or greater increased in the levels fo the serum glutamic-
oxaloacetic transaminase (SGOT), serum glutamic-pyruvic transaminase (SGPT) or serum
ammonia.

No more reasonable explanation for the cerebral and hepatic abnormalities."

Lab abnormalities associated with Reye syndrome include elevated liver function tests (ALT,
AST, bilirubin), hyperammonemia, abnormal coagulation studies, elevated amylase, and lipase,
decreased serum bicarbonate and lab values consistent with dehydration. The most common lab
finding is an early rise in ammonia occurring within 1 to 2 days of mental status changes. If
lumbar puncture is performed to obtain CSF, the leukocyte count must be below 8 to meet
diagnostic criteria. Opening pressure may be elevated in later clinical stages of disease but may
remain normal early on. [8][9][10] 

Treatment / Management
Reye syndrome is a rapidly progressing disease that may require invasive procedures early on to
maintain hemodynamically stability and adequate respiratory function.  These may include
placement of central venous access, airway intubation, and placement of a Foley catheter to
monitor urine output. Additional specialized procedures such as liver biopsy and intracranial
pressure monitoring may also be indicated.[11][2][12]

Treatment of Reye syndrome is mainly supportive and requires close monitoring of multiple
clinical parameters best accomplished in an intensive care unit setting. Aggressive treatment may
be required to correct the following serum abnormalities: 

 Hypoglycemia may be treated with dextrose-containing fluids (D50, D10, D5, etc) with a
serum glucose goal of 100-120mg/dl.
 Acidosis may be treated with sodium bicarbonate (attention not to over correct or correct
too rapidly) and ventilation management.
 Hyperammonemia may be treated with phenylacetate-sodium benzoate (Immunol) or
sodium polystyrene sulfate (Kayexalate) but may require hemodialysis if level greater
than 500mcg/dl.
 Coaguloathy may be treated (especially before invasive procedures or with clinically
significant bleeding) using cryoprecipitate, fresh frozen plasma (FFP), or Vitamin K.

Measures to target treatment of increased ICP may include:

 Elevating the head of the bed to 30 degrees

 Control of fever to prevent increased cerebral metabolism and rigors
 ICP monitoring
 Lasix administration
 Careful fluid regulation to prevent overhydration
 Sedation and analgesia
 Mannitol or hypertonic saline
 Seizure treatment and subsequent prophylaxis
Differential Diagnosis
 Drug toxicity
 Hypoglycemia
 Encephalitis
 Meningitis
 Lead and other heavy metal toxicities
 Intracranial bleeding
 Mushroom toxicity

Complications
 Seizures
 Cerebral herniation
 Aspiration pneumonia
 Cardiac arrhythmias
 Cardiovascular collapse
 Pancreatitis
 Gastrointestinal bleeding
 Respiratory failure
 Renal failure
 Sepsis
 Death

Consultations
 Pediatrician
 Neurologist
 Hepatologist

Pearls and Other Issues

Signs and symptoms of Reye syndrome should prompt strong suspicion and investigation for
undiagnosed inborn errors of metabolism (IEM). Features such as lack of viral prodrome, family
history of IEM, a family history of unexplained encephalopathy, pre-existing neurologic
symptoms, and patient age less than one year make the diagnosis of Reye syndrome less likely.

Enhancing Healthcare Team Outcomes

Given the high mortality of Reye syndrome despite treatment, the focus today is on prevention.
Besides physicians, the nurse and the pharmacist are in a prime position to educate the parents
about risk factors for the disorder. The family should be told to avoid the use of salicylates in
children. Further, the parents should be educated about the symptoms and signs of Reyes
syndrome and when to seek immediate help. Finally, the CDC recommends that all children over
the age of 6 months should receive the influenza vaccine. The pharmacist should always speak to
the family about the safe use of medications in children and alternative options for the
management of fever and pain.[13][14][15]

Outcomes

Over the past 4 decades, the mortality rate of Reye syndrome has dropped from 60% to about
20%, chiefly due to early recognition and aggressive management. By preventing increased
intracranial pressure and edema, death can be avoided in many children. For those who survive,
full recovery has been noted in about two-thirds of patients. However, those children with
elevated levels of ammonia usually have residual neurological deficits.[16][17] (Level III)

Questions
To access free multiple choice questions on this topic, click here.

References
1.
Mund ME, Gyo C, Brüggmann D, Quarcoo D, Groneberg DA. Acetylsalicylic acid as a
potential pediatric health hazard: legislative aspects concerning accidental intoxications
in the European Union. J Occup Med Toxicol. 2016;11:32. [PMC free article:
PMC4944482] [PubMed: 27418941]
2.
Brannelly NT, Hamilton-Shield JP, Killard AJ. The Measurement of Ammonia in Human
Breath and its Potential in Clinical Diagnostics. Crit Rev Anal Chem. 2016
Nov;46(6):490-501. [PubMed: 26907707]
3.
Tasker RC. Update on pediatric neurocritical care. Paediatr Anaesth. 2014 Jul;24(7):717-
23. [PubMed: 24698020]
4.
Ahrens-Nicklas RC, Edmondson AC, Ficicioglu C. An 8-year-old girl with abdominal
pain and mental status changes. Pediatr Emerg Care. 2015 Jun;31(6):459-62. [PubMed:
26035505]
5.
Chornomydz I, Boyarchuk O, Chornomydz A. REYE (RAY'S) SYNDROME: A
PROBLEM EVERYONE SHOULD REMEMBER. Georgian Med News. 2017 Nov;
(272):110-118. [PubMed: 29227269]
6.
Kramer MS. Kids versus trees: Reye's syndrome and spraying for spruce budworm in
New Brunswick. J Clin Epidemiol. 2009 Jun;62(6):578-81. [PubMed: 19345558]
7.
 Uppala R, Dudiak B, Beck ME, Bharathi SS, Zhang Y, Stolz DB, Goetzman ES. Aspirin
increases mitochondrial fatty acid oxidation. Biochem. Biophys. Res. Commun. 2017 Jan
08;482(2):346-351. [PMC free article: PMC5195905] [PubMed: 27856258]
8.
Clauson KA, Santamarina ML, Buettner CM, Cauffield JS. Evaluation of presence of
aspirin-related warnings with willow bark. Ann Pharmacother. 2005 Jul-Aug;39(7-
8):1234-7. [PubMed: 15928264]
9.
Matsuishi T, Yamaguchi Y, Terasawa K, Ohtaki E, Kimura A, Yamashita F. The
differential diagnosis of Reye syndrome: muscle biopsy evaluation. Brain Dev.
1987;9(6):610-4. [PubMed: 3445923]
10.
Mitchell RA, Arcinue EL, Partin JC, Partin JS, Ram ML, Chang CH, Smialek J, Sarnaik
A. Quantitative evaluation of the extent of hepatic enzyme changes in Reye syndrome
compared with normal liver or with non-Reye liver disorders: objective criteria for
animal models. Pediatr. Res. 1985 Jan;19(1):19-22. [PubMed: 3969310]
11.
Belkengren RP, Sapala S. Reye syndrome: clinical guidelines for practitioners in
ambulatory care. Pediatr Nurs. 1981 Mar-Apr;7(2):26-8. [PubMed: 6907833]
12.
Selves A, Ruiz S, Crognier L, Conil JM, Bonneville F, Georges B, Dupuy M, Fourcade
O, Geeraerts T. [Aspirin and its danger: Reye syndrome in young adult]. Ann Fr Anesth
Reanim. 2013 Nov;32(11):814-6. [PubMed: 24161294]
13.
Johnson CC, Ownby DR. Have the efforts to prevent aspirin-related Reye's syndrome
fuelled an increase in asthma? Clin. Exp. Allergy. 2011 Mar;41(3):296-8. [PMC free
article: PMC5571754] [PubMed: 21294782]
14.
Sullivan KM, Belay ED, Durbin RE, Foster DA, Nordenberg DF. Epidemiology of
Reye's syndrome, United States, 1991-1994: comparison of CDC surveillance and
hospital admission data. Neuroepidemiology. 2000 Nov-Dec;19(6):338-44. [PubMed:
11060509]
15.
Ross-Degnan D. Changing behavior to maintain a healthy home. Pediatr. Infect. Dis. J.
2000 Oct;19(10 Suppl):S117-9. [PubMed: 11052401]
16.
Belay ED, Bresee JS, Holman RC, Khan AS, Shahriari A, Schonberger LB. Reye's
syndrome in the United States from 1981 through 1997. N. Engl. J. Med. 1999 May
06;340(18):1377-82. [PubMed: 10228187]
17.
Rochat RW, Heath CW, Chu SY, Marchbanks PA. Maternal and child health epidemic-
assistance investigations, 1946-2005. Am. J. Epidemiol. 2011 Dec 01;174(11 Suppl):S80-
8. [PubMed: 22135396]
Copyright © 2020, StatPearls Publishing LLC.
This book is distributed under the terms of the Creative Commons Attribution 4.0 International
License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication,
adaptation, distribution, and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, a link is provided to the Creative
Commons license, and any changes made are indicated.

Bookshelf ID: NBK526101PMID: 30252357