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Adrenal apoplexy caused by fulminant sepsis in 20-year-old healthy male?: case report

  • Case report
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Central European Journal of Medicine

Abstract

Introduction. Bilateral massive adrenal hemorrhage (BMAH) is a rare catastrophic condition that manifests with acute adrenal insufficiency. Death can occur within a few hours or after many days. BMAH in association with fulminant septicemia and sepsis occurring in children and young adults is also known as the Waterhouse-Friderichsen syndrome. Fulminant sepsis associated with purpura is lethal in 40–70% of patients. Case report. The abrupt onset of fever with sore throat occurred in a 20-year old man. Next day in the early morning, he complained of severe symptoms: generalized weakness, shortness of breath and myalgia. Few hours later petechial rash occur. Within 30 hours from first symptoms he died in hospital. On autopsy, there were macroscopic bilateral areas of adrenal hemorrhage. Autopsy also revealed hemorrhage in almost all organs and tissues. Microbiological blood culture and toxicological finding was negative. Discussion. In our case, very high levels of procalcitonin and D-dimer, with all other clinically and autopsy findings, was directing medical examiners that a main cause of death was fulminant bacterial sepsis. Blood culture did not reveal any bacteria, so the cause of BMAH stays uncovered. The bacteria that most often cause fulminant sepsis connected with BMAH and death within 12–24 hours from first symptoms is N. meningitidis. It is very likely that N. meningitidis caused BMAH in our case, but it will stay in domain of speculation.

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References

  1. Kovacs KA, Lam YM and Pater JL. Bilateral massive adrenal hemorrhage assessment of putative risk factors by the case-control method. Medicine 2001;80:45–53

    Article  CAS  PubMed  Google Scholar 

  2. Tsokos M. Fatal Waterhouse-Friderichsen syndrome due to Ewingella americana infection. The American Journal of Forensic Medicine and Pathology 2003;24(1):41–44

    PubMed  Google Scholar 

  3. Ringkananon U, Khovidhunkit W, Vongthavaravat V, Sridama V, Lalitanantpong S and Snabboon T. Adrenal crisis due to bilateral adrenal hemorrhage in primary antiphospholipid syndrome. J Med Assoc Thai 2005;88(4):534–537

    PubMed  Google Scholar 

  4. Guarner J, Paddock CD, Bartlett J and Zaki SR. Adrenal gland hemorrhage in patients with fatal bacterial infections. Modern Pathology 2008;21:1113–1120

    Article  PubMed  Google Scholar 

  5. Szabo S, Huttner I, Kovacs K, Horvath E, Szabo D and Horner HC. Pathogenesis of experimental adrenal hemorrhagic necrosis (“Apoplexy”). Ultrastructural, biochemical, neuropharmacologic, and blood coagulation studies with acrylonitrile in the rat. Lab Invest 1980;42:533–545

    CAS  PubMed  Google Scholar 

  6. Rao RH. Bilateral massive adrenal hemorrhage. Med Clin North Am 1995;79:107–129

    CAS  PubMed  Google Scholar 

  7. Dempfle CE. Coagulopathy of sepsis. Thromb Haemost 2004;91:213–224

    CAS  PubMed  Google Scholar 

  8. Arlt W, Allolio B. Adrenal insuffi ciency. The Lancet 2003;361(9372):1881–1893

    Article  CAS  Google Scholar 

  9. Prigent H, Maxime V and Annane D. Science review: Mechanisms of impaired adrenal function in sepsis and molecular actions of glucocorticoids. Critical Care 2004, 8:243–252

    Article  PubMed  Google Scholar 

  10. Harris P and Bennett A. Waterhouse-Friderichsen syndrome. N Engl J Med 2001;345(11):841

    CAS  PubMed  Google Scholar 

  11. Varon J, Chen K and Sternbach GL. Rupert Waterhouse and Carl Friderichsen: adrenal apoplexy. J Emerg Med. 1998 Jul–Aug;16(4):643–647

    Article  CAS  PubMed  Google Scholar 

  12. Levin J and Cluff L. Endotoxemia and adrenal hemorrhage: Mechanisam of Waterhouse-Friderichsen syndrome. The Journal of Experimental Medicine 1964;121:247–260

    Article  Google Scholar 

  13. McKinney WP and Agner RC. Waterhouse-Friderichsen syndrome caused by Haemophilus influenzae type b in an immunocompetent young adult. Southern Medical Journal 1989;82(12):1571–3

    Article  CAS  PubMed  Google Scholar 

  14. Gertner M, Rodriguez L, Barnett SH and Shah K. Group A beta-hemolytic streptococcus and Waterhouse-Friderichsen syndrome. Pediatric Infectious Disease Journal 1992;11(7):595–596

    Article  CAS  PubMed  Google Scholar 

  15. Bramley PN, Shah P, Williams DJ and Losowsky MS. Pneumococcal Waterhouse-Friderichsen syndrome despite a normal spleen. Postgraduate Medical Journal 1989;65(767):687–688

    Article  CAS  PubMed  Google Scholar 

  16. Hamilton D, Harris MD, Foweraker J and Gresham GA. Waterhouse-Friderichsen syndrome as a result of non-meningococcal infection. J Clin Pathol 2004;57:208–209

    Article  CAS  PubMed  Google Scholar 

  17. Betrosian AP, Berlet T and Agarwal B. Purpura Fulminans in Sepsis. American Journal of the Medical Sciences 2006;332(6):339–145

    Article  PubMed  Google Scholar 

  18. Giraud T, Dhainaut JF, Schremmer B, Regnier B, Desjars P, Loirat P, Journois D and Lanore JJ. Adult overwhelming meningococcal purpura. A study of 35 cases, 1977–1989. Archives of Internal Medicine 1991;151(2):310–316

    Article  CAS  PubMed  Google Scholar 

  19. Gamper G, Oschatz E, Herkner H, Paul G, Burgmann H, Janata K, Röggla M and Laggner A. N. Sepsis-associated purpura fulminans in adults. Wiener Klinische Wochenschrift 2001;113(3–4):107–112

    CAS  PubMed  Google Scholar 

  20. Tsokos M. Postmortem measurement of serum procalcitonin concentration in Waterhouse-Friderichsen syndrome. Virchows Arch 2002;441:629–631

    Article  PubMed  Google Scholar 

  21. Schrag B, Roux-Lombard P, Schneiter D, Vaucher P, Mangin P and Palmiere C. Evaluation of C-reactive protein, procalcitonin, tumor necrosis factor alpha, interleukin-6, and interleukin-8 as diagnostic parameters in sepsis-related fatalities. International Journal of Legal Medicine 2011. Published online: http://www.springerlink.com/content/9667n22n7827u257/fulltext.pdf

    Google Scholar 

  22. Al-Nawas B, Krammer I and Shah PM. Procalcitonin in diagnosis of severe infections. Eur J Med Res 1996;1:331–333

    CAS  PubMed  Google Scholar 

  23. Brunkhorst FM, Eberhard OK and Brunkhorst R. Discrimination of infectious and noninfectious causes of early acute respiratory distress syndrome by procalcitonin. Crit Care Med 1997;27:2172–2176

    Article  Google Scholar 

  24. Schröder J, Staubach K-H, Zabel P, Stüber F and Kremer B. Procalcitonin as a marker of severity in septic shock. Langenbecks Arch Surg 1999;384:33–38

    Article  PubMed  Google Scholar 

  25. Liaudat S, Dayer E, Praz G, Bille J and Troillet N. Usefulness of procalcitonin serum level for the diagnosis of bacteremia. Eur J Clin Microbiol Infect Dis 2001;20:524–527

    Article  CAS  PubMed  Google Scholar 

  26. Tsokos M. Pathology of Sepsis. In: Essentials of Autopsy Practice. Pages: 39–84.

  27. Roberts FJ. Procurement, interpretation and value of postmortem cultures. Eur J Clin Microbiol Infect Dis 1998;17:821–827

    Article  CAS  PubMed  Google Scholar 

  28. Tabacco J, Suniega E, Sarabchi F and Mitsani D. Fatal meningococcemia. Journal of Community Hospital Internal Medicine Perspectives 2011

    Google Scholar 

  29. Waldum HL and Fuglesang JE. Fulminant meningococcemia starting as an acute gastroenteritis. Scandinavian Journal of Infectious Diseases 1977;9(4):309–310

    CAS  PubMed  Google Scholar 

  30. Hussein A, Naschitz Y and Yeshurun D. Fulminant meningococcemia presenting as a gastroenteritislike syndrome. Harefuah 1999;137(9):371–372

    CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Institute of Forensic Medicine, Medical Faculty, University of Nis, 18000, Nis, Serbia

    Ivan Stojanović, Jovan Stojanović, Miodrag Zdravković, Aleksandra Antović, Miroslav Milić & Stevan Todorović

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  1. Ivan Stojanović
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  2. Jovan Stojanović
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  3. Miodrag Zdravković
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  4. Aleksandra Antović
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  6. Stevan Todorović
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Correspondence to Ivan Stojanović.

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Stojanović, I., Stojanović, J., Zdravković, M. et al. Adrenal apoplexy caused by fulminant sepsis in 20-year-old healthy male?: case report. cent.eur.j.med 8, 485–488 (2013). https://doi.org/10.2478/s11536-013-0157-6

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  • DOI: https://doi.org/10.2478/s11536-013-0157-6

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