An 18-month-old child recovering from influenza is given repeated doses of aspirin for fever. Three days later she develops intractable vomiting, altered sensorium and hepatomegaly with elevated transaminases and hypoglycaemia. The condition and its underlying pathology are:

• A Haemorrhagic disease of the newborn: vitamin K deficiency from platelet inhibition
• B Acute salicylate poisoning: uncoupling of oxidative phosphorylation with primary respiratory alkalosis
• C Aspirin-induced metabolic acidosis: accumulation of salicylic acid as a fixed acid burden
• D Reye syndrome: mitochondrial injury with microvesicular fatty change in the liver and cerebral oedema ✓

Explanation

Aspirin use during viral illness in children is associated with Reye syndrome, characterised by encephalopathy and fatty infiltration of the liver with mitochondrial dysfunction, hypoglycaemia and raised transaminases. This association led to warnings against aspirin in febrile children, and paracetamol or ibuprofen are preferred. Simple salicylism presents with tinnitus, hyperventilation and mixed acid-base disturbance rather than hepatomegaly, and platelet inhibition causes bleeding, not this syndrome.

Reference: Nelson Textbook of Pediatrics, 21st ed.

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