A 5-year-old given aspirin for a febrile viral illness improves initially, then develops persistent vomiting, agitation, and drowsiness. Blood glucose is 45 mg/dL, AST is markedly elevated, and ammonia level is raised. CSF is acellular. What is the most likely diagnosis?

• A Kawasaki disease
• B Diabetic ketoacidosis
• C Acute bacterial meningitis
• D Reye syndrome ✓

Explanation

This is Reye syndrome: encephalopathy with fatty degeneration of the liver following a viral illness, classically influenza or varicella, in a child given aspirin. Hypoglycemia, hyperammonemia, and transaminase elevation with an acellular CSF distinguish it from meningitis, while absence of ketosis and dehydration distinguishes it from diabetic ketoacidosis. This mitochondrial injury is precisely why aspirin is avoided in febrile children, a fact also relevant to its cautious use in Kawasaki disease.

Reference: Nelson Textbook of Pediatrics, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.