eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Reye Syndrome: Differential Diagnoses & Workup

Author: Debra L Weiner, MD, PhD, Attending Physician, Division of Emergency Medicine, Children's Hospital, Boston; Assistant Professor, Department of Pediatrics, Harvard Medical School
Contributor Information and Disclosures

Updated: Feb 3, 2009

Differential Diagnoses

Encephalitis
Plant Poisoning, Hypoglycemics
Hepatitis
Sepsis
Intracranial bleed
Toxicity, Antidepressant
Intussusception with altered level of consciousness
Toxicity, Clonidine
Meningitis
Toxicity, Mushroom - Amatoxin
Pediatrics, Gastroenteritis
Toxicity, Organophosphate and Carbamate
Pediatrics, Hypoglycemia
Toxicity, Salicylate
Pediatrics, Inborn Errors of Metabolism
Toxicity, Valproate
Pediatrics, Meningitis and Encephalitis
Pediatrics, Sudden Infant Death Syndrome
Plant Poisoning, Herbs

Other Problems to Be Considered

Differential diagnosis includes conditions that can cause vomiting and altered level of consciousness. The distinction between Reye and Reye-like syndrome is often unclear.

Workup

Laboratory Studies

  • Ammonia: Ammonia level as high as 1.5 times normal (up to 1200 mcg/dL) 24-48 hours after the onset of mental status changes is the most frequent laboratory abnormality. Ammonia level may return to normal in stages 4 and 5.
  • Transaminases levels: ALT and AST levels increase to 3 times normal but may return to normal by stages 4 or 5.
  • Bilirubin: Bilirubin levels are >2 mg/dL (usually <3 mg/dL) in 10-15% of patients. If direct bilirubin level is >15% of total or total is >3 mg/dL, consider other diagnoses.
  • Prothrombin time (PT) and activated partial thromboplastin time (aPTT) are prolonged >1.5-fold in more than 50% of patients.
  • Lipase and amylase: These levels are elevated.
  • Serum bicarbonate: This level is decreased secondary to vomiting.
  • BUN and creatinine: These levels are elevated.
  • Glucose: Expect hypoglycemia, particularly in children younger than 1 year.
  • Lactic dehydrogenase (LDH): This level may be high or low.
  • Anion gap and venous blood gas: Determine anion gap and venous blood gas level to evaluate for metabolic acidosis.
  • Urine specific gravity and ketones: Specific gravity is increased; 80% of patients have ketonuria.

Imaging Studies

  • Head CT scanning may reveal cerebral edema, but the results are usually normal.

Other Tests

  • Free fatty acids and amino acids (eg, glutamine, alanine, lysine): These levels may be elevated.
  • Factors II, VII, IX, X, fibrinogen: These levels may be low due to the disruption of synthetic activities in the liver. Consumption may also contribute to low levels of coagulation factors. Platelets are usually normal.
  • Electroencephalogram (EEG) may reveal slow-wave activity in the early stages and flattened waves in advanced stages.
  • CSF opening pressure, CSF WBCs: Lumbar puncture (LP) should only be performed in hemodynamically stable patients. Opening pressure may or may not be increased; WBCs (usually lymphocytes) are 8/mm3 or fewer (8 X 109/L or fewer).
  • Workup to exclude IEM must be performed and should include evaluation for defects of fatty-acid oxidation, amino and organic acidurias, urea-cycle defects, and disorders of carbohydrate metabolism. For additional information, see the eMedicine article Pediatrics, Inborn Errors of Metabolism.

Procedures

  • Vascular access - Arterial and/or central venous
  • Lumbar puncture if patient is hemodynamically stable and no signs of increased ICP
  • Intubation to maintain airway and ventilation and to manage intracranial pressure
  • Nasogastric tube placement to decompress the abdomen
  • Bladder catheterization to monitor urine output
  • Percutaneous liver biopsy may be indicated to exclude IEM or toxic liver disease.
  • Placement of an intracranial device for intracranial pressure monitoring is indicated for patients with increased intracranial pressure.
  • Coagulopathy must be corrected before invasive procedures.

More on Pediatrics, Reye Syndrome

Overview: Pediatrics, Reye Syndrome
Differential Diagnoses & Workup: Pediatrics, Reye Syndrome
Treatment & Medication: Pediatrics, Reye Syndrome
Follow-up: Pediatrics, Reye Syndrome
References
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References

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  2. CDC. National Reye syndrome surveillance--United States, 1982 and 1983. MMWR Morb Mortal Wkly Rep. Feb 3 1984;33(4):41-2. [Medline].

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  4. New World Encyclopedia. Reye's Syndrome. Last updated September 5, 2008. Available at http://www.newworldencyclopedia.org/entry/Reye%27s_syndrome.

  5. Lovejoy FH Jr, Smith AL, Bresnan MJ, Wood JN, Victor DI, Adams PC. Clinical staging in Reye syndrome. Am J Dis Child. Jul 1974;128(1):36-41. [Medline].

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Further Reading

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Keywords

Reye's syndrome, Reye syndrome, acute noninflammatory encephalopathy, inborn error of metabolism, IEM, Reye syndrome in children, hepatic failure, upper respiratory tract infection, URTI, influenza, varicella, gastroenteritis, use of aspirin, aspirin use in children

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Contributor Information and Disclosures

Author

Debra L Weiner, MD, PhD, Attending Physician, Division of Emergency Medicine, Children's Hospital, Boston; Assistant Professor, Department of Pediatrics, Harvard Medical School
Disclosure: Nothing to disclose.

Medical Editor

Garry Wilkes, MBBS, FACEM, Director of Emergency Medicine, Bunbury Health Service, Western Australia Country Health Service; Adjunct Associate Professor, School of Exercise, Biomedical and Health Sciences, Faculty of Computing, Health and Science, Edith Cowan University; Medical Director, St John Ambulance Service
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Assistant Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: none None None

 
 
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