Endocrine Abstracts

A 57-year-old female who was previously healthy was admitted to hospital with a 2-week history of abdominal pain. On admission, she was tachycardic, tachypnoeic, hypotensive, and had abdominal tenderness. Her initial investigations revealed a neutrophilia with her biochemistry showing hyponatraemia (sodium of 124 mmol/l (135–145)) and normokalaemia (potassium of 4.7 mmol/l (3.5–5.5)). She had an urgent abdominal CT scan which showed evidence of a tubo-ovarian abscess for which she underwent emergency laparascopic surgery. The CT scan also revealed bilaterally bulky adrenal glands. Following her surgery, she was admitted into the intensive care unit where despite improvement in her inflammatory markers, she had persistent hypotension. She was empirically started on hydrocortisone with an improvement in her blood pressure and sodium. Microbiological analysis of the pus within the ovarian abscess revealed streptococcus oralis as the responsible pathogen. She then had a short Synacthen test (with prior temporary withdrawal of hydrocortisone) which showed evidence of primary adrenal insufficiency with cortisol readings of 195, 208, and 207 nmol/l (>550), respectively, at 0, 30, and 60 min (following 250 μg of i.m. tetracosactide) and a concurrent ACTH reading (at time 0) was 56 ng/l (0–46). Her measured anti-adrenal antibodies were negative. A subsequent CT of her adrenal glands showed cystic attenuation of the glands suggesting atrophy following earlier haemorrhage of the gland. She was discharged from hospital on replacement doses of hydrocortisone after having received intensive education. This case demonstrates the development of Waterhouse Friederichsen syndrome (haemorrhagic adrenalitis) due to Streptococcus oralis and even though the typical association has historically been with Neisseria meningitides, it alerts clinicians to the possibility of other pathogens. It emphasises the need to search for adrenal insufficiency in patients with refractory hypotension even in the context of septicaemia.