Waterhouse-Friderichsen syndrome after infection with group A streptococcus

A Rare Case of Waterhouse-Friderichsen Syndrome Without Purpura Secondary to Haemophilus Influenzae

The Waterhouse-Friderichsen syndrome is an entity consisting of shock, petechial rash and haemorrhages in both adrenal glands leading to adrenal failure. This syndrome is usually secondary to meningococcal septicaemia, but there are many documented cases caused by other bacteria. Purpura is an essential part of the syndrome, but it is not always there. In the current study, a case of Waterhouse-Friderichsen syndrome without purpura in an elderly patient with Haemophilus influenzae bacteraemia has been described. This patient was being managed for sepsis due to pneumonia and an incidental finding of bilateral adrenal haemorrhage was made on a CT of the thorax which was meant to evaluate empyema. This case shows the need to suspect bilateral adrenal haemorrhage in every patient with septic shock.

The Evaluation and Management of Toxic Shock Syndrome in the Emergency Department: A Review of the Literature

BACKGROUND

Toxic shock syndrome (TSS) is a severe, toxin-mediated illness that can mimic several other diseases and is lethal if not recognized and treated appropriately.

OBJECTIVE

This review provides an emergency medicine evidence-based summary of the current evaluation and treatment of TSS.

DISCUSSION

The most common etiologic agents are Staphylococcus aureus and Streptococcus pyogenes. Sources of TSS include postsurgical wounds, postpartum, postabortion, burns, soft tissue injuries, pharyngitis, and focal infections. Symptoms are due to toxin production and infection focus. Early symptoms include fever, chills, malaise, rash, vomiting, diarrhea, and hypotension. Diffuse erythema and desquamation may occur later in the disease course. Laboratory assessment may demonstrate anemia, thrombocytopenia, elevated liver enzymes, and abnormal coagulation studies. Diagnostic criteria are available to facilitate the diagnosis, but they should not be relied on for definitive diagnosis. Rather, specific situations should trigger consideration of this disease process. Treatment involves intravenous fluids, source control, and antibiotics. Antibiotics should include a penicillinase-resistant penicillin, cephalosporin, or vancomycin (in methicillin-resistant S. aureus prevalent areas) along with either clindamycin or linezolid.

CONCLUSION

TSS is a potentially deadly disease requiring prompt recognition and treatment. Focused history, physical examination, and laboratory testing are important for the diagnosis and management of this disease. Understanding the evaluation and treatment of TSS can assist providers with effectively managing these patients.

Group A streptococcal toxic shock syndrome secondary to necrotizing pelvic inflammatory disease in a postmenopausal woman

Group A β-hemolytic streptococcus (GAS) is well known to cause upper respiratory tract or cutaneous infections, but some more virulent species of GAS can lead to a rapidly progressive life threatening soft tissue necrotizing infection and streptococcal toxic shock syndrome (STSS). In the modern era, GAS infections within the female reproductive tract leading to STSS are unusual and are often the result of retained products of conception or intrauterine devices. This report describes a case of GAS necrotizing pelvic infection in a previously healthy menopausal woman with no obvious portal of entry. Her clinical course rapidly progressed to septic shock and multiorgan failure. She required multiple surgeries in addition to targeted antimicrobials and aggressive management of shock and organ failures. After a prolonged hospital stay, she had a full recovery.

Bilateral adrenal haemorrhage associated with heparin-induced thrombocytopaenia during treatment of Fournier gangrene

We present a case of bilateral adrenal haemorrhage (BAH) associated with heparin-induced thrombocytopaenia (HIT) in a 61-year-old man admitted to hospital for the treatment of Fournier's gangrene. He presented to hospital with scrotal swelling and fever, and developed spreading erythaema and a gangrenous scrotum. His scrotum was surgically debrided and intravenous broad-spectrum antibiotics were administered. Unfractionated heparin was given postoperatively for venous thromboembolism prophylaxis. The patient deteriorated clinically 8-11 days postoperatively with delirium, chest pain and severe hypertension followed by hypotension and thrombocytopaenia. Abdominal CT scan revealed bilateral adrenal haemorrhage. Antibodies to the heparin-platelet factor 4 complex were present. HIT-associated BAH was diagnosed and heparin was discontinued. Intravenous bivalirudin and hydrocortisone were started, with rapid improvement in clinical status. BAH is a rare complication of HIT and should be considered in the postoperative patient with unexplained clinical deterioration.

Waterhouse Friderichsen syndrome complicating fulminant Enterobacter cloacae sepsis in a preterm infant: the unresolved issue of corticosteroids

Bilateral adrenal hemorrhage can complicate severe sepsis in the neonate and is most commonly attributed to meningococcal disease; however, it can be caused by other etiologic agents as well. We report herein a fatal case of Enterobacter cloacae sepsis in a preterm infant, resulting in massive adrenal hemorrhages. This is the first documented case of adrenal hemorrhage following infection with this pathogen.

Waterhouse-friderichsen syndrome in an adult patient with meningococcal meningitis

Waterhouse-Friderichsen syndrome is one of the fatal complications of meningococcal infection. Here we report a fatal case of this syndrome due to Neisseria meningitidis in a 29-year-old male patient who was admitted with high-grade fever and chills and vomiting since 7 days, a skin rash over the abdomen and trunk, and altered sensorium since 2 days. On examination, the signs of meningitis were present along with the hemorrhagic rash. The diagnosis of adrenal hemorrhage was confirmed by computerized tomographic scan findings. The patient was started on intravenous ceftriaxone, and the cerebrospinal fluid was processed for bacterial culture, which yielded growth of N meningitidis. The patient's condition deteriorated; he developed purpura along with a fall in platelet count, and died due to shock. This case is being reported as such a complication is comparatively rare in this antibiotic era, especially in adults, and starting steroids like dexamethasone prior to antibacterial therapy may be useful to diminish the inflammation brought about by bacterial cell death and thus help in reducing the otherwise high mortality in these cases.

Streptococcal toxic shock syndrome

Introduction. Streptococcal toxic shock syndrome is now recognized as a toxin-mediated, multisystem illness. It is characterized by an early onset of shock with multiorgan failure and continues to be associated with high morbidity and mortality, caused by group A Streptococcus pyogenes. The symptoms for staphylococcal and streptococcal toxic shock syndrome are similar. Streptococcal toxic shock syndrome was not well described until 1993, when children who had suffered from varicella presented roughly 2-4 weeks later with a clinical syndrome highly suggestive of toxic shock syndrome. Characteristics, complications and therapy. It is characterized by a sudden onset of fever, chills, vomiting, diarrhea, muscle aches and rash. It can rapidly progress to severe and intractable hypotension and multisystem dysfunction. Almost every organ system can be involved. Complications of streptococcal toxic shock syndrome may include kidney failure, liver failure and even death. Crystalloids and inotropic agents are used to treat the hypovolemic shock aggressively, with close monitoring of the patient?s mean arterial pressure and central venous pressure. An immediate and aggressive management of hypovolemic shock is essential in streptococcal toxic shock syndrome. Targeted antibiotics are indicated; penicillin or a betalactam antibiotic is used for treating group A streptococci, and clindamycin has emerged as a key portion of the standard treatment.

Choque séptico puerperal por Streptococcus β-hemolítico e síndrome de Waterhouse-Friderichsen

É relatado caso excepcional de puérpera de 15 anos com choque séptico pelo Streptococcus beta-hemolítico do grupo A e síndrome de Waterhouse-Friderichsen, observado à necropsia. São revistos aspectos do diagnóstico, patogênese e evolução da infecção (sepse) puerperal associada à hemorragia e insuficiência das supra-renais.

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.

Adrenal infections

Adrenal infections are an important but under-recognized clinical entity. The adrenal gland can be infected by a myriad of pathogens including fungi, viruses, parasites, and bacteria. Infection can directly or indirectly cause tissue damage and alteration in endocrine function. Direct damage occurs via microbial replication and local production of toxic compounds, such as endotoxins. Indirect damage results from alterations in the regulation of a host's immunologic and endocrine mediators in response to damage by a microbe at a distant site. Variations in pathogen tropism, adrenal anatomy, and host immune integrity contribute to the progression of active disease and discernable adrenal dysfunction. Early recognition and intervention in the case of adrenal infection can significantly improve outcome, demonstrating the need for increased clinical suspicion in the appropriate clinical setting.

Severe bacterial infections of the skin: uncommon presentations

Although most bacterial infections of the skin prove to be minor in nature, a few such dermatologic entities are significant, to the point of even being fatal. Their course can be extremely rapid and can lead to dreadful complications. The mortality rate is usually up to 30% to 50% and depends upon the type of infection, underlying disease, and immune status. Patients suffering them usually need to be hospitalized, sometimes in intensive care or burn units. They should be treated systemically with appropriate antimicrobial therapy plus aggressive supportive care. The two life-threatening skin infections which are most commonly experienced are toxin-mediated staphylococcal and streptococcal disorders; one could overlap the other. Several other related entities will also be discussed.

Recognition and Management of Adrenal Emergencies

Although clinical conditions associated with dysfunction of the ad-renal gland are often subtle, even insidious, in their presentation,and diagnosis and treatment usually are confined to outpatient clinics and offices, there are several situations that warrant the attention of emergency physicians. Recognition of the spectrum of presentations of pheochromocytoma, adrenal insufficiency, and pituitary apoplexy, and the sequelae of corticosteroid therapy and withdrawal, are critically important areas to emergency medicine. Prompt diagnosis with appropriate treatment and referral will reduce morbidity and mortality in many patients each year. A related topic pertinent to emergency physicians is the management of incidental adrenal masses that are discovered on abdominal radio-logic imaging.

Disseminated intravascular coagulation and coagulation disorders

PURPOSE OF REVIEW

An update on recent developments in diagnosis and treatment of disseminated intravascular coagulation.

RECENT FINDINGS

Disseminated intravascular coagulation is defined as a typical disease condition with laboratory findings indicating massive coagulation activation and reduction in procoagulant capacity. Clinical syndromes associated with the condition are consumption coagulopathy, sepsis-induced purpura fulminans, and viral hemorrhagic fevers. Consumption coagulopathy is observed in patients with sepsis, aortic aneurysms, acute promyelocytic leukemia, and other disseminated malignancies. Sepsis-induced purpura fulminans is characterized by microvascular occlusion causing hemorrhagic necrosis of the skin and organ failure. Viral hemorrhagic fevers result in massively increased tissue factor production in monocytes and macrophages, inducing microvascular thrombosis and consumption of platelets and coagulation factors. Current scoring systems do not distinguish between patients with asymptomatic disseminated intravascular coagulation, consumption coagulopathy and thrombotic syndromes. Patients with sepsis may be identified by activated partial thromboplastin time waveform analysis performed as part of routine coagulation testing. Drotrecogin alpha (activated) reduces mortality in patients with severe sepsis with and without disseminated intravascular coagulation and has been used in patients with sepsis-induced purpura fulminans. Tifacogin does not reduce mortality in severe sepsis associated with impaired coagulation. Patients with heterozygous factor V Leiden mutation and severe sepsis showed a lower 28-day mortality than patients without this mutation, supporting the assumption that an enhanced level of coagulation activation may be beneficial in patients with severe sepsis.

SUMMARY

Whereas antithrombin and tifacogin failed to improve clinical outcome in severe sepsis, drotrecogin alpha (activated) increased the chances of survival of patients with severe sepsis with and without disseminated intravascular coagulation.

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.

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.

Infectious causes of adrenal insufficiency

More than 150 years ago, Thomas Addison first described the clinical features and pathogenesis of adrenal insufficiency. At that time, tuberculosis was the most common cause of this disease. The pathway to diagnosis and treatment of Addison's disease has been well described. However, determining the cause of the disorder remains a challenge. It is important to consider recently described infectious agents in the pathogenesis of Addison's disease. Mycobacterial, bacterial, viral, and fungal infections may lead to the development of adrenal insufficiency. Skin, pulmonary, and imaging findings can aid the clinician in making a prompt diagnosis of specific infections, which is crucial because early identification of infectious causes of Addison's disease may enable recovery of adrenal function. This review describes the clinical presentations of the multiple infectious causes of adrenal insufficiency.

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.