BACKGROUND
Waterhouse-Friderichsen syndrome, also known as acute
adrenal insufficiency due to adrenal gland
hemorrhage, is an uncommon and frequently fatal condition classically presenting with
fever,
shock,
rash, and coagulopathy. Although most often associated with Meningococcemia, many other etiologies have been implicated, including reports of
Staphylococcus aureus infection on autopsy examinations. This report details an adult intravenous drug user with adrenal
hemorrhage associated with methicillin-resistant Staphylococcus aureus (MRSA)
bacteremia. CASE REPORT A 58-year-old man with a history of intravenous
drug use presented to the hospital with weakness. Vitals were initially normal and exam findings were notable for decreased right-sided motor strength. Magnetic resonance imaging (MRI) revealed a cervical
epidural abscess with
spinal cord compression. Despite initiation of broad-spectrum
antibiotics and intravenous fluids, the patient progressed to
shock, requiring vasopressor administration, and his blood cultures later grew MRSA. Further imaging of the abdomen/pelvis was completed, revealing bilateral adrenal
hemorrhage. Random
cortisol at that time was 5.6 µg/dL, confirming a diagnosis of
critical illness-related
corticosteroid insufficiency in addition to likely septic and spinal
shock. The patient was initiated on
hydrocortisone with improvement in his
hypotension. He was transitioned to
prednisone and
fludrocortisone in addition to 8 weeks of
antibiotics after achieving clinical stability. CONCLUSIONS This report brings to attention the risk of adrenal
hemorrhage and acute
adrenal insufficiency as a sequela of the relatively common illness of Staphylococcus aureus
bacteremia. As symptoms of
adrenal insufficiency can overlap with
septic shock related to the primary condition, this diagnosis requires a high index of suspicion in the
critically ill patient.