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

• Authors: Ivan Stojanović , Jovan Stojanović , Miodrag Zdravković , Aleksandra Antović , Miroslav Milić , Stevan Todorović
• Languages of publication: EN

Abstracts

EN

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.

Keywords

EN

Adrenal apoplexy; Fulminant sepsis; Autopsy

• Publisher: De Gruyter Open
• Journal: Open Medicine
• Year: 2013
• Volume: 8
• Issue: 4
• Pages: 485-488

Dates

published

1 - 8 - 2013

online

12 - 6 - 2013

Contributors

author

Ivan Stojanović

• Institute of Forensic Medicine, Medical Faculty, University of Nis, 18000, Nis, Serbia

author

Jovan Stojanović

• Institute of Forensic Medicine, Medical Faculty, University of Nis, 18000, Nis, Serbia

author

Miodrag Zdravković

• Institute of Forensic Medicine, Medical Faculty, University of Nis, 18000, Nis, Serbia

author

Aleksandra Antović

• Institute of Forensic Medicine, Medical Faculty, University of Nis, 18000, Nis, Serbia

author

Miroslav Milić

• Institute of Forensic Medicine, Medical Faculty, University of Nis, 18000, Nis, Serbia

author

Stevan Todorović

• Institute of Forensic Medicine, Medical Faculty, University of Nis, 18000, Nis, Serbia

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 http://dx.doi.org/10.1097/00005792-200101000-00005[Crossref]
• [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][Crossref]
• [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
• [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 http://dx.doi.org/10.1038/modpathol.2008.98[Crossref][WoS]
• [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 [PubMed]
• [6] Rao RH. Bilateral massive adrenal hemorrhage. Med Clin North Am 1995;79:107–129
• [7] Dempfle CE. Coagulopathy of sepsis. Thromb Haemost 2004;91:213–224
• [8] Arlt W, Allolio B. Adrenal insuffi ciency. The Lancet 2003;361(9372):1881–1893 http://dx.doi.org/10.1016/S0140-6736(03)13492-7[Crossref]
• [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 http://dx.doi.org/10.1186/cc2878[Crossref]
• [10] Harris P and Bennett A. Waterhouse-Friderichsen syndrome. N Engl J Med 2001;345(11):841
• [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 http://dx.doi.org/10.1016/S0736-4679(98)00061-4[Crossref]
• [12] Levin J and Cluff L. Endotoxemia and adrenal hemorrhage: Mechanisam of Waterhouse-Friderichsen syndrome. The Journal of Experimental Medicine 1964;121:247–260 http://dx.doi.org/10.1084/jem.121.2.247[Crossref]
• [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 http://dx.doi.org/10.1097/00007611-198912000-00029[Crossref]
• [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 http://dx.doi.org/10.1097/00006454-199207000-00019[Crossref]
• [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 http://dx.doi.org/10.1136/pgmj.65.767.687[Crossref]
• [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 http://dx.doi.org/10.1136/jcp.2003.9936[Crossref]
• [17] Betrosian AP, Berlet T and Agarwal B. Purpura Fulminans in Sepsis. American Journal of the Medical Sciences 2006;332(6):339–145 http://dx.doi.org/10.1097/00000441-200612000-00006[Crossref]
• [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 http://dx.doi.org/10.1001/archinte.1991.00400020068015[Crossref]
• [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 [WoS]
• [20] Tsokos M. Postmortem measurement of serum procalcitonin concentration in Waterhouse-Friderichsen syndrome. Virchows Arch 2002;441:629–631 http://dx.doi.org/10.1007/s00428-002-0675-0[Crossref]
• [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 [WoS]
• [22] Al-Nawas B, Krammer I and Shah PM. Procalcitonin in diagnosis of severe infections. Eur J Med Res 1996;1:331–333
• [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 http://dx.doi.org/10.1097/00003246-199910000-00016[Crossref]
• [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 http://dx.doi.org/10.1007/s004230050170[Crossref]
• [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 http://dx.doi.org/10.1007/s100960100548[Crossref]
• [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 http://dx.doi.org/10.1007/s100960050200[Crossref]
• [28] Tabacco J, Suniega E, Sarabchi F and Mitsani D. Fatal meningococcemia. Journal of Community Hospital Internal Medicine Perspectives 2011
• [29] Waldum HL and Fuglesang JE. Fulminant meningococcemia starting as an acute gastroenteritis. Scandinavian Journal of Infectious Diseases 1977;9(4):309–310 [PubMed][Crossref]
• [30] Hussein A, Naschitz Y and Yeshurun D. Fulminant meningococcemia presenting as a gastroenteritislike syndrome. Harefuah 1999;137(9):371–372

Identifiers

DOI

10.2478/s11536-013-0157-6