Sir.—We read with interest the article by Chaves-Carballo et al1 concerning the hemorrhagic shock and encephalopathy (HSE) syndrome. We recently cared for two infants with this entity2 and we believe that the gastrointestinal tract is the source of this devastating illness. Approximately 74 infants and children with HSE have been described in the literature, most of whom presented with a prodromal illness consisting of vomiting and diarrhea.
The origin of HSE remains unexplained, but the multisystem failure seen in both HSE and heatstroke (HS) may be a final common pathway of an unexplained mediator. The hyperpyrexia may be the result of high metabolic requirements coupled with compensatory vasoconstriction. The shock state leads to increasing splanchnic vasoconstriction (which may actually be worsened by hyperpyrexia) that contributes to the release of these potentially toxic mediators. The vasoconstriction, caused by any combination of hypotension, hyperthermia, or gut ischemia, will allow