Endocrine Abstracts

Background: Bilateral adrenal haemorrhage (Waterhouse–Friderichsen syndrome) is a rare consequence of sepsis (usually a result of meningococcal infection), with an estimated 15% mortality. Despite the predominant association with meningococcal infection, there are other recognised aetiologies: sepsis resulting from other organisms, and non-infectious causes, such as anticoagulant treatment, trauma and postoperative adrenal haemorrhage.

Case report: A 53-year-old man was admitted in the Urology department, to undergo a retropubic radical prostatectomy (prostatic adenocarcinoma). Other medical history: thromboangiitis obliterans, managed with warfarin and acetylsalicylic acid. No complications on the postoperative period; prophylactic antibiotherapy was started with ceftriaxone. On the 7^th postoperative-day, the patient had a lipothymia episode, with a decrease of consciousness level (Glasgow 9), hypotensive and subfebrile condition. Blood evaluation consistent with sepsis: leukopenia, thrombocytopenia, raised transaminases, C-protein reactive and troponin, and severe hyposmolar hyponatremia (113 mEq/l). No anomalies detected on neurologic evaluation or cranial computerized-tomography (CT). Antibiotherapy was changed to Piperacillin-Tazobactam. A random ACTH, cortisol and TSH were performed as workup for hyponatremia: ACTH 141 pg/ml (0–46), cortisol 2.5 ug/dl (4.3–23), normal TSH. Abdominal CT scanning was performed: grossly abnormal adrenal glands bilaterally, with masses compatible with hematomas. On the 8^th day he began intravenous hydrocortisone in high doses, with recovery of natremia and consciousness level. Blood and urine cultures results were negative (probably “decapitated”). When discharged, the patient was asymptomatic, with normal blood evaluation, and taking long-term hydrocortisone and fludrocortisone. So far, the patient has been asymptomatic and is being monitored by the Endocrinology department.

Conclusions: This case highlights the importance of awareness for symptoms/signs and electrolyte variation when assessing surgical patients post-operatively. The early recognition of this disease allowed immediate treatment, avoiding a worse outcome and leading to a quick recovery. There are risk factors, as anticoagulation therapy, predisposing the development of this rare, but serious, disease.