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.

[The Waterhouse-Friderichsen syndrome]

BACKGROUND

The Waterhouse-Friderichsen syndrome (WFS) is a serious illness associated with a high mortality rate and characterized by septic shock and signs of adrenocortical insufficiency.

CASE DESCRIPTION

A 33-year-old male was seen in the emergency department with severe abdominal and back pain with diffuse mottled skin and rapidly progressive petechiae all over his body. Laboratory results showed severe lactate acidosis with renal dysfunction and indications of diffuse intravascular coagulation. Because he had signs of progressive septic shock, the patient was admitted to the ICU. There he subsequently developed hypoglycaemia (glucose < 0.1 mmol/l) and CPR had to be performed twice - the patient died shortly afterwards. Autopsy showed bilateral necrosis and haemorrhage of the adrenal glands, indicative of the diagnosis of WFS. Streptococcus pneumoniae was identified.

CONCLUSION

In case of sepsis, with fever, rapidly expanding petechiae and purpura the Waterhouse-Friderichsen syndrome should be considered. Intensive therapy with antibiotics, fluids, vasopressors, and corticosteroids should be initiated immediately.

A rare case of Waterhouse- Friderichsen syndrome during primary Varicella zoster infection

Primary Varicella zoster virus infection in adults is associated with a higher risk of complications when compared with the benign disease course of primary infection during childhood. We present a rare complication of adult primary Varicella zoster in the form of acute, irreversible adrenal insufficiency due to bilateral adrenal haemorrhage, which is also known as the WaterhouseFriderichsensyndrome.

[A 52-year-old woman with acute shock and purpura fulminans. Pneumococcal sepsis]

We report a 52-year-old female patient admitted with fever, chills, and myalgias since the previous day. On the day of admission she had a generalized seizure. The patient had no previous illnesses. Laboratory investigations showed consumptive coagulopathy with clinical manifestations of shock and development of multiple organ failure. Pneumococci were detected in blood cultures. Furthermore the skin showed purpura fulminans all over. The patient died within 24 h after admission in the intensive care unit. On autopsy, in addition to adrenal and myocardial hemorrhages, hypoplasia of the spleen was found. Fulminant pneumococcal sepsis is a life-threatening disease that occurs in patients with risk factors like splenic hypoplasia or asplenia. Sometimes a fulminant pneumococcal sepsis may be the first clinical manifestation of a hitherto unknown splenic hypoplasia. In this context the general recommendation of vaccination against pneumococci in patients with risk factors like splenic hypoplasia or asplenia, in patients older than 60, and in children from 2 months onward has to be emphasized.

[Recombinant human activated protein C in the treatment of children with meningococcal purpura fulminans]

Meningococcal purpura fulminans (MPF) produces high mortality and morbidity, despite appropriate standard therapy. Administration of recombinant human activated protein C (rhAPC) has been successfully applied in adults with MPF and pediatric studies are under way. We report three pediatric patients with MPF treated with rhAPC as compassionate therapy. In two of these patients, positive clinical and laboratory effects were observed and both children achieved full recovery. The remaining patient died after 36 hours from refractory multiorgan failure. No rhAPC-related adverse effects were detected. The reported cases highlight the usefulness of rhAPC in children with MPF at least as a rescue compassionate treatment. Further clinical trials are needed to better delineate its efficacy and administration schedule in children.

[Waterhouse-Friderichsen cases in the archives of ZMS PAM--epidemiological conditions and diagnostic difficulties]

15 cases of meningococcal infections from 2003-2004 were discussed in the study. Their therapy ended in failure and they had been typically autopsied in our Forensic Med. Department. During the autopsy material for classical microbiological investigations was collected. That type of death is characterised with pathognomonic and autopsy image. The problem is the microbiological identification of the pathogen group and type. It is connected with the characteristic of the analysed material and the biological features of Neisseria meningitidis. The molecular and genetic methods show their usefulness in this type of diagnostic of the properly selected and collected material which typically are: cerebrospinal fluid, brain tissue with the arachnoid membranes and spleen tissue.

Waterhouse-Friderichsen syndrome as a result of non-meningococcal infection

Waterhouse-Friderichsen syndrome--massive adrenal haemorrhage in the setting of overwhelming clinical sepsis--is usually taken at necropsy to indicate meningococcal infection, and may be the only evidence of this pathogen. This report describes three fatal cases of the syndrome in which the causative organism proved to be a streptococcus. The organisms were detected during routine coroners' autopsies with histology and microbiological investigations. In two cases, the syndrome followed Streptococcus pneumoniae infection and in a third beta haemolytic streptococcus group A. Thus, adrenal haemorrhage alone cannot be taken to indicate meningococcal disease and other pathogens, particularly streptococcus, must be considered.

Fatal Waterhouse-Friderichsen syndrome due to Ewingella americana infection

A fatal case of Waterhouse-Friderichsen syndrome resulting from infection in a previously healthy 74-year-old woman is reported. The patient died suddenly within 14 hours after presentation. The diagnosis of Waterhouse-Friderichsen syndrome as the cause of death was established post mortem based on autopsy findings, microscopic examination, measurement of serum procalcitonin concentration (113 ng/ml), and outcome of postmortem bacteriologic cultures that grew in heart and spleen blood samples. Since the introduction of as a new group in the family in 1983, more recent case studies have established its clinical significance and pathogenic potential to cause severe, life-threatening bacteremia and sepsis. is a rare pathogen that should be added to the list of unusual bacteria causing Waterhouse-Friderichsen syndrome.

[Acute adrenocortical insufficiency]

Severe acute adrenocortical insufficiency or adrenal crisis are often elusive diagnoses that may result in severe morbidity and mortality when undiagnosed or ineffectively treated. Although more than 50 steroids are produced within the adrenal cortex, cortisol and aldosterone are far the most abundant and physiologically active. In primary adrenocortical insufficiency, glucocorticoid and mineral-corticoid properties are lost; however, in secondary adrenocortical insufficiency (i.e., secondary to disease or suppression of the hypothalamic-pituitary axis), mineralocorticoid function is preserved. Every emergency physician should be familiar with adrenocortical insufficiency--a potentially life-threatening entity. The initial diagnosis and decision to treat are presumptive and are based on history, physical examination, and, occasionally, laboratory findings. Delay in treatment while attempting to confirm this diagnosis can result in poor patient outcomes. This article review data about physiology, pathophysiology of the adrenal cortex, physiologic effects of glucocorticoids, aldosterone, causes of primary and secondary adrenal insufficiency, frequency, clinical picture, laboratory and imaging studies of adrenal crisis, laboratory evaluation of adrenal function and emergency therapy, replacement therapy, mortality/morbidity of this pathology.

Fatal pneumococcal Waterhouse-Friderichsen syndrome

There have only been six deaths reported in the English literature due to disseminated intravascular coagulation and Waterhouse-Friderichsen syndrome complicating pneumococcemia in otherwise healthy persons with normal spleens. Four of these deaths occurred in children and two in adults. A case of fulminant pneumococcemia complicated by disseminated intravascular coagulation and Waterhouse-Friderichsen syndrome in an otherwise healthy adult with a normal spleen is presented. The case is typical of the course of fulminant pneumococcal sepsis and highlights some of the difficulties experienced by rural general practitioners and rural retrieval services. Mechanisms by which Pneumococcus can elicit fulminant sepsis are discussed, although there is no explanation as to why this may occur in the setting of normal splenic function.

The protective effect of brachial plexus palsy in purpura fulminans

Acute infectious purpura fulminans is reported in a 16-month-old male with a history of posttraumatic asplenia and complete left brachial plexus palsy. This patient developed peripheral necrosis of both lower extremities and the right upper extremity, whereas the left upper extremity was completely spared from ischemia and tissue damage. Amputation of four digits on the right hand and debridement of both lower extremities were required. This patient demonstrated the protective effect of a traumatic sympathectomy, which suggests the requirement of an intact sympathetic reflex in the development of purpura fulminans.

Sepsis-associated purpura fulminans in adults

Sepsis-associated purpura fulminans is defined as septicemia, shock, disseminated intravascular coagulation and circulatory failure leading to multiple organ dysfunction. 40-70% of patients with sepsis-associated purpura fulminans die. Early prognostic factors in adults have not been well delineated yet. Aim of our study was 1) to evaluate currently used scoring systems for meningococcal septicemia in the setting of sepsis-associated purpura fulminans and 2) to assess if other parameters are feasible as early prognostic factors. From 1.1 1994-31.12.1998 twelve patients (female: 7; mean age: 31 (21; 43) years) were studied. Six patients (50%) died within 2 hours and 7 days after admission despite standard intensive treatment. On admission non-survivors had a more pronounced degree of disseminated intravascular coagulation compared to survivors (platelet count 18000 (15000; 45000) G/l vs. 119.000 (111000; 152000) G/l, (p = 0.03); fibrinogen 67 (50; 108) mg/dl vs. 356 (234; 483) mg/dl, (p = 0.02); PTZ 28% (20%; 30%) vs. 44% (35%; 51%), (p = 0.05); aPTT 120 (120; 128) sec vs. 46 (44; 69) sec, (p = 0.001). Severity of lactic acidosis was significantly higher in non-survivors than in survivors (pH 7.08 (6.92; 7.21) vs. pH 7.4 (7.25; 7.4), (p = 0.02); lactate 13.5 (11; 15) mval/l vs. 6.0 (4.4; 6) mval/l, (p = 0.02); data presented as median (25-75% interquartile range). In our patients the Glasgow Meningococcal Septicemia Prognostic Score (GMSPS) and the Niklasson-Score failed to distinguish between survivors and non-survivors (GMSPS 7 (6; 11) vs 7.5 (7; 9) out of 15; predicted mortality according to Niklasson-Score 73% vs 88%). There was no difference in the APACHE II Score (22 (18.5, 24) vs 22 (20.25, 26)). The severity of disseminated intravascular coagulation assessed by routine laboratory parameters and the degree of lactic acidosis on admission were the strongest predictors of outcome in patients with sepsis-associated purpura fulminans. Scoring systems developed for patients with meningococcal septicemia are of limited value in the setting of sepsis-associated purpura fulminans.

Waterhouse-Friderichsen syndrome secondary to Capnocytophaga canimorsus septicemia and demonstration of bacteremia by peripheral blood smear

Waterhouse-Friderichsen syndrome caused by Capnocytophaga canimorsus septicemia was fatal in a previously healthy 47-year-old woman. The patient died suddenly in less than 12 hours after presentation, in spite of supportive measures, including ventilation, antibiotic coverage, pressor therapy, and multiple transfusions of blood products. The diagnosis of infection due to an unusual organism was suspected earlier in the course of management after review of the peripheral blood smear. The importance of the findings in the blood smear and their correlation with infection due to this organism are discussed.

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.

[Diagnosis of an infected thrombus of the inferior vena cava with ultrasound and computerized tomography]

The incidence of central venous catheter-associated thrombosis is up to 66%; nevertheless, in most cases it is of little clinical importance. A rare, but serious complication is infection of a catheter-associated thrombosis, which occurs in 7-16%. We report the case of a 16-year-old male patient, who suffered from meningitis and Waterhouse-Friderichsen syndrome. After initial improvement in the intensive care unit, he developed septic temperatures, caused by an infected thrombus of a central venous catheter in the inferior vena cava. Color-coded ultrasound showed hyperechogenic signals and missing flow detection at the catheter tip. Computed tomography showed air bubbles in the thrombosed catheter tip and confirmed the diagnosis. Vascular surgery was done and an infected, 17-cm-long infected thrombus was removed. The recent literature on this topic is reviewed.

[Recommendations for the diagnosis and therapy of meningitis, Waterhouse-Friderichsen syndrome and encephalitis in childhood]

Representatives of the working group of "Neuropaediatrics" and "Infectology" like to present recommendations on diagnostics and treatment of infectious diseases on the CNS. Individual opinions can not be considered in recommendations always. Therefore we have to understand these recommendations in this way that individual decisions will not be restricted in special situations.

[Waterhouse Fridericksen syndrome in adults. Radiological diagnosis. Apropos of a case]

Waterhouse-Fridericksen syndrome is a rare possibility in the adult. The case reported here included full radiological evaluation. The diagnosis was made by ultrasonographic and CT scan imaging. Nuclear magnetic resonance imaging was obtained for the purposes of documentation.

Ultrasound diagnosis of adrenal hemorrhage in meningococcemia

Two cases of adrenal hemorrhage in meningococcemia detected by ultrasound are reported. Antemortem detection of adrenal pathology may have important prognostic and therapeutic implications. The sonographic appearance may be echo-free, mixed, or echogenic. Abdominal ultrasound examination can be an effective non-invasive tool in diagnosing adrenal hemorrhage.

Waterhouse-Friderichsen syndrome without purpura due to Haemophilus influenzae group B

A second recorded case of Waterhouse-Friderichsen syndrome, without purpura, due to Haemophilus influenzae is described. It is suggested that the absence of purpura should not preclude the diagnosis of the Waterhouse-Friderichsen syndrome due to this organism.

[Acute disease with fever with rapidly developing shock and ecchymoses]

The history, the clinical and laboratory findings of a 13 year old boy, who has initially shown the signs and symptoms of febrile infectious disease are presented. The petechial and purpuric skin lesions have been suspected to be a rash. Accurate diagnosis therefore has been delayed up to 20 hours after onset of specific skin lesions. A very rapid deterioration made adequate treatment unsuccessful. It is pointed out that prompt accurate diagnosis and medical treatment in this serious infectious disease may improve the overall poor prognosis.

[Early diagnosis, early therapy and prognosis of epidemic cerebrospinal meningitis]

The authors convened a special study for purposes of determining early signs of epidemic cerebrospinal meningitis and for the dependence of the prognosis from early etiotropic and pathogenetic therapy. On the basis of a study of 93 cases criteria of early diagnosis are being given. Unlike the data in literature, in 60.2% of the cases it was possible to initiate treatment during the first hours of the disease and in 94.6% -- not later than 48 hours. In most of the cases the disease had a grave course. Changed consciousness was observed in 55.9%, an increased amount of protein in the CSF -- in 58%. In 8 cases there was a syndrome of acute renal insufficiency. Despite these facts all the patients recovered. The authors come to the conclusion that prognosis may be significantly improved in cases of early diagnosis (during the first hours), intensive penicillin therapy (both intravenously and kanamicin into the carotid artery). The authors suggest that during reconvalescence it is feasible to prescribe resolving (pyrogenal lydase) and general therapy.