Resident Physician San Antonio, Texas, United States
Background: Waterhouse–Friderichsen syndrome (WFS) is a rare, rapidly fatal complication of overwhelming sepsis characterized by adrenal hemorrhage and acute adrenal insufficiency. Although classically associated with Neisseria meningitidis, WFS caused by non-meningococcal gram-negative organisms is exceedingly uncommon and frequently underrecognized.
Methods: This case report describes a single-patient case of fulminant septic shock complicated by bilateral adrenal hemorrhage consistent with WFS. Clinical presentation, laboratory findings, imaging studies, microbiologic data, management, and outcomes were reviewed.
Outcome: An 83-year-old male presented with altered mental status, hypotension, fever, and signs of septic shock following recent international travel. Initial evaluation revealed lactic acidosis, leukopenia, thrombocytopenia, transaminitis, acute kidney injury, and atrial flutter. Despite early initiation of broad-spectrum antibiotics, multiple vasopressors, and mechanical ventilation, the patient rapidly progressed to multiorgan failure. Computed tomography of the chest, abdomen, and pelvis demonstrated large bilateral adrenal masses consistent with adrenal hemorrhage. Blood cultures grew Escherichia coli and Klebsiella pneumoniae. Based on the clinical picture and imaging findings, a diagnosis of Waterhouse–Friderichsen syndrome was made. Stress-dose corticosteroids, including hydrocortisone and fludrocortisone, were initiated. The patient required escalating vasopressor support and continuous renal replacement therapy due to severe metabolic acidosis and hemodynamic instability. Despite aggressive critical care management, the patient’s condition continued to deteriorate, and he ultimately expired.
Conclusion: This case demonstrates that non-meningococcal gram-negative organisms, including Escherichia coli and Klebsiella pneumoniae, can precipitate fulminant septic shock complicated by Waterhouse–Friderichsen syndrome with fatal outcomes. Early recognition, prompt imaging, and initiation of stress-dose corticosteroids may be critical in improving outcomes in this rare but devastating condition.
