Fulminating meningitis with Waterhouse-Friderichsen syndrome due to Neisseria gonorrhoeae

Waterhouse-Friderichsen syndrome, septic adrenal apoplexy

Waterhouse-Friderichsen syndrome is a rare but potentially fatal disorder of the adrenal gland characterized by bilateral adrenal hemorrhage. It is classically a result of meningococcal sepsis and presents acutely with features of shock, petechial rashes, abdominal pain, and non-specific symptoms such as headache, fatigue, and vomiting. Treatment consists of fluid resuscitation, corticosteroid replacement, and possibly surgery. The prognosis is poor despite treatment. This chapter will review the etiology, pathogenesis, clinical features, and management of the disease.

Adrenal gland hemorrhage in patients with fatal bacterial infections

A wide spectrum of adrenal gland pathology is seen during bacterial infections. Hemorrhage is particularly associated with meningococcemia, while abscesses have been described with several neonatal infections. We studied adrenal gland histopathology of 65 patients with bacterial infections documented in a variety of tissues by using immunohistochemistry. The infections diagnosed included Neisseria meningitidies, group A streptococcus, Rickettsia rickettsii, Streptococcus pneumoniae, Staphylococcus aureus, Ehrlichia sp., Bacillus anthracis, Leptospira sp., Clostridium sp., Klebsiella sp., Legionella sp., Yersinia pestis, and Treponema pallidum. Bacteria were detected in the adrenal of 40 (61%) cases. Adrenal hemorrhage was present in 39 (60%) cases. Bacteria or bacterial antigens were observed in 31 (79%) of the cases with adrenal hemorrhage including 14 with N. meningitidis, four with R. rickettsii, four with S. pneumoniae, three with group A streptococcus, two with S. aureus, two with B. anthracis, one with T. pallidum, and one with Legionella sp. Bacterial antigens were observed in nine of 26 non-hemorrhagic adrenal glands that showed inflammatory foci (four cases), edema (two cases), congestion (two cases), or necrosis (one case). Hemorrhage is the most frequent adrenal gland pathology observed in fatal bacterial infections. Bacteria and bacterial antigens are frequently seen in adrenal glands with hemorrhage and may play a pathogenic role. Although N. meningitidis is the most frequent bacteria associated with adrenal gland pathology, a broad collection of bacteria can also cause adrenal lesions.

Gonococcal meningitis diagnosed by DNA amplification: case report and review of the literature

We report a case of gonococcal meningitis diagnosed by DNA amplification. A 47-year old man presented with a 4-day history of asymmetric painful swelling of his ankles and wrists, and skin rash. He had sex with men only but was HIV negative. Headache and photophobia led to a cerebrospinal fluid (CSF) examination that revealed meningitis. Cultures were negative but we detected Neisseria gonorrhoeae in his urine and CSF using a GC/chlamydia DNA amplification assay. The patient was discharged without sequela after 14 days of intravenous ceftriaxone.

Staphylococcus aureus sepsis and the Waterhouse-Friderichsen syndrome in children

Staphylococcus aureus has increasingly been recognized as a cause of severe invasive illness. We describe three children who died at our institution after rapidly progressive clinical deterioration from this infection, with necrotizing pneumonia and multiple-organ-system involvement. The identification of bilateral adrenal hemorrhage at autopsy was characteristic of the Waterhouse-Friderichsen syndrome, a constellation of findings usually associated with fulminant meningococcemia. The close genetic relationship among the three responsible isolates of S. aureus, one susceptible to methicillin and two resistant to methicillin, underscores the close relationship between virulent methicillin-susceptible S. aureus and methicillin-resistant S. aureus isolates now circulating in the community.

Waterhouse-Friderichsen syndrome after infection with group A streptococcus

We report a case of Waterhouse-Friderichsen syndrome associated with group A streptococcus (GAS) toxic shock syndrome in a previously healthy man. The patient presented with neck pain and fevers of 2 days' duration. Computed tomography of the neck revealed a mass in the retropharyngeal space, suggesting an abscess. Despite prompt treatment with appropriate antibiotics, the patient experienced a fulminant course and died within 8 hours of presentation. Antemortem blood cultures grew GAS positive for exotoxins A, B, and C. Postmortem examination revealed bilateral adrenal hemorrhage, consistent with Waterhouse-Friderichsen syndrome. Immunohistochemical analysis of the adrenal glands revealed the presence of GAS antigens. However, no disseminated intravascular coagulation was evident. This case demonstrates that adrenal hemorrhage can occur without associated coagulopathy and may result directly from the action of bacterial toxins.

Rupert Waterhouse and Carl Friderichsen: adrenal apoplexy

The Waterhouse-Friderichsen (WFS) syndrome, also known as purpura fulminans, is described as acute hemorrhagic necrosis of the adrenal glands and is most often caused by meningococcal infection. This clinical entity is more frequently seen in the pediatric than the adult population and is associated with a high morbidity and mortality. The initial presenting complaints for patients with the WFS usually include a diversity of nonspecific, vague symptoms such as cough, dizziness, headache, sore throat, chills, rigors, weakness, malaise, restlessness, apprehension, myalgias, arthralgias, and fever. These symptoms are usually abrupt in their onset. Petechiae are present in approximately 50-60% of patients. The clinical diagnosis of WFS may be relatively straightforward or extremely challenging. Patients who appear in the initial and nontoxic-appearing stage without any skin lesions may be difficult to distinguish from a benign viral illness. When a patient presents with fever and petechiae, WFS must be considered, even when the patient has a non-toxic appearance. Due to the rapid progression and often devastating consequences, therapy should be instituted as soon as the diagnosis is suspected.

Disseminated gonococcal infection (DGI) and gonococcal arthritis (GCA): II. Clinical manifestations, diagnosis, complications, treatment, and prevention

This is the second part of an integrated review of disseminated gonococcal infection (DGI) and gonococcal arthritis (GCA). It covers clinical manifestations, spectrum of GCA, diagnosis and treatment. These disorders are important since DGI may be the most frequent form of acute arthritis in sexually active younger females, and other selected groups. Although the spectrum of disease is varied, it may be classified into stages and clinical subgroups. N. gonorrhoeae strains causing DGI in the U.S. have been highly sensitive to penicillin. Such findings require revision in beliefs that high-dose intravenous penicillin is needed for effective initial therapy of GCA. Recommended treatment protocols for localized gonorrhea and DGI are reviewed as well as the occurrence and implications for treatment of penicillinase-producing N. gonorrhoeae (PPNG) infection in the U.S.

Meningitis caused by maltose-negative variant of Neisseria meningitidis

A maltose-negative variant of Neisseria meningitidis, Slaterus Y, was recovered from a patient with meningitis. A report of the case is presented and the medical-legal significance of such an isolate is briefly discussed.

Interaction of gonococci with phagocytic leukocytes from men and mice

The interaction of human and mouse phagocytic leukocytes with representative virulent (F62-T1) and avirulent (F62-T4, RD-5) strains of Neisseria gonorrhoeae was studied in vitro. Leukocyte monolayers were incubated with gonococci for 30 min at 37 C, washed repeatedly, reincubated with fresh medium, and sampled for viable bacteria at intervals. After the initial incubation period and washing, human leukocytes retained larger numbers of viable T1 than of T4. During the subsequent 120 min of incubation, the numbers of viable T1 remained approximately constant, whereas viable counts of T4 declined by about two-thirds. In contrast, mouse leukocytes under similar conditions destroyed 70% of both types of gonococci. When human bactericidal serum was applied to infected human leukocytes, it had no effect on T4 but inactivated over 50% of T1. It is concluded that T4 are phagocytized by human leukocytes and are thus exposed to internal digestion, but are protected from bactericidal serum. T1, on the other hand, either adhere to the surface of the leukocytes or remain located so that they are neither digested by the leukocytes nor protected from bactericidal serum.