Clinical Staging in Reye Syndrome-Reply

Sir .—We have read with interest the discussion of Drs. Lazoff and Renschler regarding survival in a patient with stage V Reye syndrome. Survival from stage IV disease is now well recognized, occurring in patients who have been treated with exchange transfusion, 1 in patients who have undergone dialysis, 2 and in patients treated with vigorous anticerebral edema measures (fluid restriction, dexamethasone, glycerol and mannitol) in our institution during the past two years. The patient described does have most of the clinical signs of stage V disease (respiratory arrest dilated pupils, and areflexia), though the existence of flaccidity, the disappearance of decerebration, and a type 4 electroencephalogram have not been alluded to in the clinical description. This is the first stage V survivor we are aware of and indicates the need for continuing active therapy once a patient has entered this stage. The aspect of therapy that allowed for survival