Reversible adrenocorticol insufficiency in fulminant meningococcemia

Abstract

A 13-year-old girl who had been well previously was admitted with fulminant meningococcemic purpura. Her plasma cortisol level was only 3 micrograms/dL and failed to rise after cosyntropin administration. Maintenance doses of corticosteroid were administered. As her infection cleared her adrenal glands were restimulated and shown to have near normal response. Replacement doses of corticosteroids should be given to patients with fulminant meningococcemia until adrenal cortical insufficiency can be excluded because of the high incidence of adrenal failure in these patients and the possibility that excessive adrenal stimulation might contribute to adrenal abnormality.

Adrenal infections

“…The Waterhouse-Friderichsen syndrome represents a paradigm for the interrelationship of host and microbe within the adrenal gland with the disease being characterized by acute adrenal gland insufficiency and profound shock. The syndrome is typically attributed to infection with Neisseria meningitidis, 18 but it may occur in fulminant infections with other microbes, including smallpox. 60 In his pioneering clinical and laboratory work, Friderichsen described the Waterhouse-Friderichsen syndrome in cases due to N. meningitidis, Streptococcus spp, Haemophilus influenzae, Corynebacterium diphtheriae, and Staphylococcus aureus, and he was able to experimentally induce adrenal hemorrhage in guinea pigs by injections of Bacillus anthracis, Clostridium tetani, Streptococcus spp and several Gram-negative bacilli.…”

“…[2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] Due to the non-specific nature of the symptomatology and laboratory manifestations (e.g., fatigue, anorexia, low blood pressure, hyperkalemia, hypernatremia, hypoglycemia 1 ) and the fact that 80-90% of the gland must be destroyed before the patient will demonstrate overt Addisonian symptoms, 17 antemortem diagnosis is rare. However, prompt recognition combined with appropriate therapy early in the disease course may prove beneficial, 13,15,16,[18][19][20] thereby warranting a high clinical suspicion for adrenal involvement in the appropriate clinical scenario.…”

“…Adrenal dysfunction can also occur in response to infections at distant sites or in disseminated disease due to alterations in the host's physiochemical milieu. [14][15][16][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] It is generally understood that individuals who are responding to the stress of an illness (e.g., a systemic infection) will manifest an increase in the functioning of the hypothalamopituitary-adrenal axis (HPA-axis) leading to an overall increase in systemic corticosteroid levels. Increased cortisol secretion has been shown to shift the balance in the Th1/Th2 cell ratio towards a Th2 response.…”

Adrenal infections

“…The Waterhouse-Friderichsen syndrome represents a paradigm for the interrelationship of host and microbe within the adrenal gland with the disease being characterized by acute adrenal gland insufficiency and profound shock. The syndrome is typically attributed to infection with Neisseria meningitidis, 18 but it may occur in fulminant infections with other microbes, including smallpox. 60 In his pioneering clinical and laboratory work, Friderichsen described the Waterhouse-Friderichsen syndrome in cases due to N. meningitidis, Streptococcus spp, Haemophilus influenzae, Corynebacterium diphtheriae, and Staphylococcus aureus, and he was able to experimentally induce adrenal hemorrhage in guinea pigs by injections of Bacillus anthracis, Clostridium tetani, Streptococcus spp and several Gram-negative bacilli.…”

“…[2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] Due to the non-specific nature of the symptomatology and laboratory manifestations (e.g., fatigue, anorexia, low blood pressure, hyperkalemia, hypernatremia, hypoglycemia 1 ) and the fact that 80-90% of the gland must be destroyed before the patient will demonstrate overt Addisonian symptoms, 17 antemortem diagnosis is rare. However, prompt recognition combined with appropriate therapy early in the disease course may prove beneficial, 13,15,16,[18][19][20] thereby warranting a high clinical suspicion for adrenal involvement in the appropriate clinical scenario.…”

“…Adrenal dysfunction can also occur in response to infections at distant sites or in disseminated disease due to alterations in the host's physiochemical milieu. [14][15][16][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] It is generally understood that individuals who are responding to the stress of an illness (e.g., a systemic infection) will manifest an increase in the functioning of the hypothalamopituitary-adrenal axis (HPA-axis) leading to an overall increase in systemic corticosteroid levels. Increased cortisol secretion has been shown to shift the balance in the Th1/Th2 cell ratio towards a Th2 response.…”

Sonographic Diagnosis of Adrenal Hemorrhage in Patients with Fulminant Meningococcal Septicemia

“…Acute adrenocortical insufficiency may occur in patients with fulminant meningococcal septicemia (9). Based on autopsy studies, there is a high correlation between low serum cortisol levels and massive bilateral adrenal hemorrhage (6, 7); However, to our knowledge, such correlation has not been established in living patients.…”

Adrenal infections

“…The Waterhouse-Friderichsen syndrome represents a paradigm for the interrelationship of host and microbe within the adrenal gland with the disease being characterized by acute adrenal gland insufficiency and profound shock. The syndrome is typically attributed to infection with Neisseria meningitidis, 18 but it may occur in fulminant infections with other microbes, including smallpox. 60 In his pioneering clinical and laboratory work, Friderichsen described the Waterhouse-Friderichsen syndrome in cases due to N. meningitidis, Streptococcus spp, Haemophilus influenzae, Corynebacterium diphtheriae, and Staphylococcus aureus, and he was able to experimentally induce adrenal hemorrhage in guinea pigs by injections of Bacillus anthracis, Clostridium tetani, Streptococcus spp and several Gram-negative bacilli.…”

“…[2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] Due to the non-specific nature of the symptomatology and laboratory manifestations (e.g., fatigue, anorexia, low blood pressure, hyperkalemia, hypernatremia, hypoglycemia 1 ) and the fact that 80-90% of the gland must be destroyed before the patient will demonstrate overt Addisonian symptoms, 17 antemortem diagnosis is rare. However, prompt recognition combined with appropriate therapy early in the disease course may prove beneficial, 13,15,16,[18][19][20] thereby warranting a high clinical suspicion for adrenal involvement in the appropriate clinical scenario.…”

“…Adrenal dysfunction can also occur in response to infections at distant sites or in disseminated disease due to alterations in the host's physiochemical milieu. [14][15][16][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] It is generally understood that individuals who are responding to the stress of an illness (e.g., a systemic infection) will manifest an increase in the functioning of the hypothalamopituitary-adrenal axis (HPA-axis) leading to an overall increase in systemic corticosteroid levels. Increased cortisol secretion has been shown to shift the balance in the Th1/Th2 cell ratio towards a Th2 response.…”

Sonographic Diagnosis of Adrenal Hemorrhage in Patients with Fulminant Meningococcal Septicemia

“…Acute adrenocortical insufficiency may occur in patients with fulminant meningococcal septicemia (9). Based on autopsy studies, there is a high correlation between low serum cortisol levels and massive bilateral adrenal hemorrhage (6, 7); However, to our knowledge, such correlation has not been established in living patients.…”

Adrenal infections

“…The Waterhouse-Friderichsen syndrome represents a paradigm for the interrelationship of host and microbe within the adrenal gland with the disease being characterized by acute adrenal gland insufficiency and profound shock. The syndrome is typically attributed to infection with Neisseria meningitidis, 18 but it may occur in fulminant infections with other microbes, including smallpox. 60 In his pioneering clinical and laboratory work, Friderichsen described the Waterhouse-Friderichsen syndrome in cases due to N. meningitidis, Streptococcus spp, Haemophilus influenzae, Corynebacterium diphtheriae, and Staphylococcus aureus, and he was able to experimentally induce adrenal hemorrhage in guinea pigs by injections of Bacillus anthracis, Clostridium tetani, Streptococcus spp and several Gram-negative bacilli.…”

“…[2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] Due to the non-specific nature of the symptomatology and laboratory manifestations (e.g., fatigue, anorexia, low blood pressure, hyperkalemia, hypernatremia, hypoglycemia 1 ) and the fact that 80-90% of the gland must be destroyed before the patient will demonstrate overt Addisonian symptoms, 17 antemortem diagnosis is rare. However, prompt recognition combined with appropriate therapy early in the disease course may prove beneficial, 13,15,16,[18][19][20] thereby warranting a high clinical suspicion for adrenal involvement in the appropriate clinical scenario.…”

“…Adrenal dysfunction can also occur in response to infections at distant sites or in disseminated disease due to alterations in the host's physiochemical milieu. [14][15][16][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32] It is generally understood that individuals who are responding to the stress of an illness (e.g., a systemic infection) will manifest an increase in the functioning of the hypothalamopituitary-adrenal axis (HPA-axis) leading to an overall increase in systemic corticosteroid levels. Increased cortisol secretion has been shown to shift the balance in the Th1/Th2 cell ratio towards a Th2 response.…”

Sonographic Diagnosis of Adrenal Hemorrhage in Patients with Fulminant Meningococcal Septicemia

“…Acute adrenocortical insufficiency may occur in patients with fulminant meningococcal septicemia (9). Based on autopsy studies, there is a high correlation between low serum cortisol levels and massive bilateral adrenal hemorrhage (6, 7); However, to our knowledge, such correlation has not been established in living patients.…”