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Encephalopathy and Fatty Degeneration of Viscera Reye's Syndrome

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Encephalopathy and Fatty Degeneration of Viscera Reye's Syndrome Arch Dis Child: first published as 10.1136/adc.48.6.411 on 1 June 1973. Downloaded from Annotation Archives of Disease in Childhood, 1973, 48, 411. Encephalopathy and fatty degeneration of viscera Reye's syndrome Encephalopathy and fatty degeneration of the relatively bloodless, greasy, and firm. In liver viscera were reported as early as 1929 (Brain, biopsy specimens fatty infiltration is seen as diffuse Hunter, and Turnbull), but it is only in the past 10 small vacuoles most prominent in the periportal years that the clinical and pathological features have areas, but there is massive fatty infiltration in been clearly defined (Mann et al., 1962; Reye, necropsy material. Liver glycogen is decreased. Morgan, and Baral, 1963; Lancet, 1969; Evans et The nuclei of the hepatocytes may contain 1 to 4 al., 1970; Guillete, Berlin, and Finkelstein, 1971). irregular enlarged nucleoli but hepatocellular Considerable problems still exist regarding many necrosis is not seen except in necropsy material. aspects of the disorder. The aetiology remains The portal tracts are normal. Electron micro- unknown and the pathogenesis is poorly understood. scopical examination of liver biopsy material The lack of striking clinical features of hepatic (Partin, Schubert, and Partin, 1971) early in the involvement may cause the disorder to be over- course of the encephalopathy shows the hepatocytes looked in life, but even if the diagnosis is made, to be universally affected by a process which results there are considerable problems in management. in swollen pleomorphic mitochondria, as well as copyright. The assessment of the relative efficacy of different small droplet triglyceride accumulation. There is forms of therapy is difficult, as it is not yet clear also proliferation of smooth endoplasmic reticulum which of the many measurable parameters which and a great increase in peroxisomes. The may be abnormal in the syndrome are the best mitochondrial abnormalities gradually improve indices of prognosis. This is a major problem in a during clinical recovery. Fat deposition is seen disorder which may follow a continuum of severity also in the renal tubules and myocardium. from the invariable fatal cases, such as those reported Chromatographic analysis of lipids shows increase http://adc.bmj.com/ initially, to milder or even subclinical cases. There in both triglycerides and free fatty acids in liver is considerable variation in the reported incidence extracts with only triglycerides increased in kidney in different areas. The incidence relative to the extracts (Bourgeois et al., 1971a). other acute encephalopathies in childhood is not While the clinical features are not pathognomonic, clear. There has even been some debate as to with a few readily available laboratory tests, the whether the syndrome can be considered a specific diagnosis can often be strongly suspected in life. entity. It may merely represent the effects of many The disorder is recognized in children aged 2 different aetiological factors acting on the same months to 15 years. The onset is typically acute on September 26, 2021 by guest. Protected metabolic pathway. The consistency of the with vomiting, disturbances of consciousness, con- reported findings do suggest, however, that the vulsions, coma, and often decerebrate posture. syndrome in childhood is a distinct pathological and There may be a history of a mild prodromal illness metabolic response of sufficient homogeneity to be from which the child was apparently improving. the basis of epidemiological and aetiological studies, Physical examinaton reveals a stuporose, agitated, and-if the diagnosis is made in life-for much hyperactive, comatose, or convulsing child, with no needed investigations of pathogenic mechanisms apparent cause. Hyperpnoea or irregular deep and their response to therapy. respirations are common and should suggest the The pathological features are well characterized. diagnosis. There are no focal neurological signs There is marked cerebral oedema, with or without and no evidence of meningeal irritation. Mild to anoxic neuronal changes and neuronal degeneration, moderate hepatomegaly is the only clinical but with no cellular infiltration or demyelination. suggestion of hepatic involvement, and even this is The liver at necropsy is swollen and tense, orange lacking in 50% of cases. The serum bilirubin to pale yellow in colour, the cut surface being level is normal or occasionally slightly increased, 411 Arch Dis Child: first published as 10.1136/adc.48.6.411 on 1 June 1973. Downloaded from 412 Alex P. Mowat but the prothrombin time is usually prolonged and hepatoma formation, are dose related and vary the serum aspartate aminotransferase level is raised. from species to species, with greatest hepatic Hypoglycaemia is common in children of less than 5 sensitivity in the young (Wogan and Pong, 1970). years, but is rarely found in older children. Administration of aflatoxins to young female Hypoxia and acidosis are frequently found. CSF Macaque monkeys produces the clinical laboratory is normal except for its sugar content which may and histopathological features of Reye's syndrome, be low. Electroencephalography shows diffuse except that hepatic necrosis is marked and there is changes with slow wave activity predominating, but bile duct hyperplasia (Bourgeois et al., 1971b). In there is no specific abnormality. These features Thailand, Olson et al. (1971) have shown that the will often permit a presumptive diagnosis of Reye's degree of aflatoxin contamination of foods follows syndrome, and histopathological confirmation by the seasonal and geographical incidence of liver biopsy may be deferred until the coagulation encephalopathy and fatty degeneration of the abnormalities are corrected. viscera. Chemical assay of the tissue of these The clinical course is often of deepening coma patients shows higher concentrations of aflatoxins and death. In the first 200 cases reported the than are found in those that die of other disorders or mortality was 80% (Guillete et al., 1971), but more in accidents. Yet family outbreaks are rare, though recent reports (see below) indicate a lower contaminated food is presumably shared. In part mortality of 25% to 70% perhaps because milder this may be attributable to the amount ingested or cases are diagnosed or management is better. the increased sensitivity of the young. Another Silverman, Roy, and Cozetto (1971) report that possibility is that aflatoxin alone will not produce the one-third of survivors had severe CNS sequelae full syndrome but will do so in the presence of other such as mental impairment, seizures, or hemiplegia. unrecognized factors. Though this association has Olson et al. (1971) and Huttenlocher (1972) found been well documented only in Thailand the fungi no significant residual effects in 21 and 8 children, producing these mycotoxins are ubiquitous and may respectively. Again, it is not clear whether these grow on many foods with maximum growth rates at differences are due to different severity of disease or 25 to 30 °C. copyright. to better care. Reye's syndrome has many features in common The incidence of the syndrome is difficult to with vomiting sickness of Jamaica (Stuart, 1970), a assess, varying from rare sporadic cases to being a disorder which is said to be much less common since leading cause of death in 1 to 6 year olds in Thailand it was appreciated that it was caused by a hypoglycin (Olson et al., 1971). Cases appear to occur in from unripe ackee fruit (Tanaka, Isselbacher, and minor outbreaks in a fairly wide area, usually Shih, 1972). without any recognized link between individual The cause of the encephalopathy is undetermined. http://adc.bmj.com/ cases (Reynolds et al., 1972; Glick et al., 1970), There is no evidence of primary CNS infection. A though more than one case may rarely occur in a toxic factor acting directly on the brain as well as the family (Thaler et al., 1970). liver has been suggested, but at present it seems No known infectious or toxic agent or metabolic more likely that the encephalopathy is secondary to abnormality has been recognized which will metabolic effects of the hepatic lesion. Apart from consistently cause the clinical biochemical and lack of jaundice, many of the features are similar to histopathological lesions. Viral infection has been acute fulminant hepatic failure. Hypoglycaemia is suggested on the basis of the recovery of viruses only one of the known metabolic lesions which could on September 26, 2021 by guest. Protected from a few patients, the frequency of varicella as be instrumental in causing the encephalopathy. the prodroxnal illness (Norman, 1968), and also Ammonia retention, which if marked carries a bad because the incidence of the syndrome increased prognosis, is also important, particularly since the concurrently with outbreaks of influenza B infection nonesterified fatty acid concentration is also raised in two epidemiological studies (Glick et al., 1970; (Bourgeois et al., 1971a). This in itself can cause Reynolds et al., 1972). Toxins that have been coma (Trauner et al., 1972; Walker et al., 1970). In considered in the aetiology include salicylates a variety of experimental animals it has been shown (Norman, 1968; Reynolds et al., 1972), pteridines that these two biochemical abnormalities have an (Curry, Guttman, and Price, 1962), and isopropyl additive effect in causing coma (Zieve et al., 1972). alcohol (Silverman et al., 1971), but the evidence is Abnormalities of many forms of intermediate weak. More important perhaps are aflatoxins, metabolism already documented, such as raised mycotoxins produced by many species of aspergillus pyruvate and lactate levels, may also contribute. If and penicillium. The hepatic effects of this group metabolic changes in hepatocytes mirror the of toxins, hepatitis with bile duct proliferation or ultrastructural changes, many other abnormalities Arch Dis Child: first published as 10.1136/adc.48.6.411 on 1 June 1973. Downloaded from Encephalopathy andfatty degeneration of viscera 413 are likely, involving, for example, amino acid and Bourgeois, C. H., Shank., R. C., Grossman, R. A., Johnsen, D.
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