Bilateral adrenal hemorrhage in the background of Escherichia coli sepsis: a case report

Abstract

BackgroundSepsis is a syndrome of life-threatening organ dysfunction caused by a dysregulated host response to infection. It can have devastating consequences, including bilateral adrenal hemorrhage, particularly in patients at high thrombotic risk, such as those with antiphospholipid syndrome and those on long-term anticoagulation.Case presentationA 49-year-old white woman re-presented to hospital with a history suggestive of sepsis. She had a medical background of primary antiphospholipid syndrome on lifelong warfarin. Ten days prior to this presentation, she had been hospitalized following Escherichia coli bacteremia, commenced on intravenous antibiotics, and discharged 2 days later with a prescribed 5-day course of oral amoxicillin. On readmission, she had ongoing fever, myalgia, malaise, and hypotension. Investigations revealed anemia with thrombocytopenia, hyponatremia, and acute-on-chronic kidney injury. Despite treatment for urosepsis, she became tachypneic, clammy, light-headed, drowsy, and hypothermic. Computed tomography revealed bilateral adrenal hemorrhage, and biochemical examination confirmed hypoadrenalism. Following discharge, she had persistent renal and hepatic injury lasting 3 months.ConclusionsEarly identification, intensive monitoring, and aggressive support may reduce the acquired thrombotic risk and avoid potentially life-threatening outcomes of sepsis.

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

“…The WFS is a rare disease and mostly fatal, and it occurs acutely in most cases [3][4][5][6][7][8][9]. It is mainly diagnosed at post-mortem; thus, the need for a high index of suspicion and urgent intervention is required.…”

“…It is mainly diagnosed at post-mortem; thus, the need for a high index of suspicion and urgent intervention is required. Neisseria meningitidis is isolated in more than 80% of WFS cases, other bacteria are Haemophilus influenzae and Pseudomonas aeruginosa, as seen in this case, Streptococcus pneumoniae, Staphylococcus aureus, group A Streptococcus, Neisseria gonorrhoeae, Proteus mirabilis, Klebsiella, and Legionella [4][5][6][7][8][9][10]. It is essential to know that bilateral adrenal haemorrhage on its own has other causes besides sepsis.…”

“…It is essential to know that bilateral adrenal haemorrhage on its own has other causes besides sepsis. These are heart failure, immense physical stress such as trauma and surgery, antiphospholipid syndrome, oral anticoagulants, heparin-induced thrombocytopaenia, underlying adrenal tumour, and pregnancy [7][8][9][10][11]. Sepsis explained the bilateral haemorrhage in this case.…”

“…It could have been worsened by direct oral anticoagulation as the patient was on apixaban and INR on admission was 3. The cause is unknown sometimes, as evidenced by documented cases of idiopathic bilateral adrenal haemorrhage [5][6][7][8][9][10][11].…”

“…Bilateral adrenal haemorrhage presents with vague symptoms, and this led to late diagnosis in this case [4][5][6][7][8][9][10][11]. It was diagnosed 10 days after admission as an incidental finding on CT thorax.…”