SHM Converge Scientific Abstract ePoster Gallery-When Hypoperfusion Hits: A Case of Waterhouse Friderichsen Syndrome

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This case report describes Waterhouse-Friderichsen syndrome (WFS), a rare and often fatal condition caused by bilateral adrenal hemorrhage, most commonly associated with severe infection and septic shock. Although classically linked to meningococcal infection and pediatric patients, WFS can also occur with other bacteria and, more rarely, noninfectious causes such as trauma or anticoagulation. Typical symptoms include fever, purpura, and shock, and mortality remains high.<br /><br />The authors present a 75-year-old woman with Crohn’s disease and a known sigmoid colon stricture who arrived with severe abdominal pain. CT imaging showed pneumoperitoneum and ascites from a perforated colon. She underwent emergent exploratory laparotomy with rectosigmoid resection, end colostomy, Hartmann’s procedure, left salpingo-oophorectomy, and pelvic washout. She received one unit of blood and was started on empiric ertapenem. Surgical cultures grew E. coli, Bacteroides, and Clostridium clostridiforme, so antibiotics were narrowed to ceftriaxone with metronidazole.<br /><br />Despite initial fluid resuscitation, the patient’s septic shock worsened and she acutely deteriorated on postoperative day five. Repeat CT of the abdomen and pelvis without contrast showed bilateral adrenal hyperdensity, suggesting WFS. Morning cortisol was low at 3.6 µg/dL, prompting immediate hydrocortisone therapy and discontinuation of anticoagulation; fludrocortisone was briefly added but stopped due to hypokalemia. After steroid treatment, she improved rapidly, bowel function returned, and she was eventually discharged home.<br /><br />The key lesson from this case is that WFS can present atypically in postoperative patients with hypoperfusion and septic shock, even without the classic rash or fever. Early abdominal imaging, recognition of adrenal hemorrhage, prompt steroid administration, and stopping anticoagulation were critical to survival. Delayed diagnosis or treatment can be fatal.

Asset Subtitle

Hannah Teaff

Meta Tag

Author List Brittanie West, Hannah Teaff, Noah Teaff

Category Clinical Vignettes

Concept Waterhouse-Friderichsen Syndrome

Concept Bilateral Adrenal Hemorrhage

Concept Septic Shock

Concept Adrenal Hemorrhage

Concept Bilateral Adrenal Hyperdensity

Distinguished Non-Finalist

Presenter Organization United Hospital Center

Presenting Author Hannah Teaff

Track Adult

Keywords

Waterhouse-Friderichsen syndrome

bilateral adrenal hemorrhage

septic shock

perforated colon

Crohn’s disease

postoperative complication

adrenal hyperdensity

hydrocortisone therapy

anticoagulation discontinuation

adrenal insufficiency

Waterhouse-Friderichsen Syndrome

Bilateral Adrenal Hemorrhage

Septic Shock

Adrenal Hemorrhage

Bilateral Adrenal Hyperdensity