(8.03) Bilateral Adrenal Hemorrhage Complicating Pneumococcal Pneumonia

Bilateral adrenal hemorrhage causing acute adrenal insufficiency and complicating bacterial sepsis is also referred to as Waterhouse-Friderchson syndrome (WFS), particularly when associated with meningococcemia.  However, WFS may occur during bacteremia and sepsis caused by other bacteria.  We present a case of pneumococcal pneumonia complicated by WFS.

Case(s) Description :

A 58-year-old woman presented to hospital with one week of productive cough, right pleuritic chest pain, fatigue, postural dizziness, nausea, and diarrhea. She was hypotensive and hypoxemic and required pressor agents and supplemental oxygen, respectively.  The patient was admitted to intensive care and received additional treatment with intravenous fluids and empiric antibiotics.  Admission laboratories were notable for acute kidney injury, lactic acidosis, and leukocytosis, and chest imaging revealed a right middle lobe infiltrate, right pleural effusion, and patchy left lower lobe opacities.  Both adrenal glands were observed to be hemorrhagically enlarged on computed tomography of the chest, prompting stress-dose hydrocortisone to be started.  Sputum cultures eventually grew S. pneumoniae.  The patient’s clinical status improved quickly, though she was discharged from hospital on hydrocortisone and fludrocortisone for management of primary adrenal insufficiency.

Discussion :

WFS is a rare but potentially fatal complication of sepsis.  The specific factor predisposing to bilateral adrenal hemorrhage is unclear, though in one autopsy series bacteria were cultured from adrenal glands in 60% of patients.  Other risk factors include treatment with anticoagulants, history of thromboembolic disease or known hypercoagulable states, surgery, and trauma.  WFS is suggested by hypotension and tachycardia occurring with fever, abdominal, flank, back, or low chest pain, nausea or vomiting, and altered mental status.  Petechiae occur in over half of meningococcemia cases.  Hyperkalemia and hyponatremia are also common.  Prompt treatment with stress dose hydrocortisone is required to prevent progression of shock.  Though most cases of WFS occur in the setting of Gram-negative sepsis, this case illustrates that WFS may also complicate cases of severe Gram-positive bacterial infections including pneumococcal pneumonia.