Adrenal Insufficiency following Septic Shock: A Case Report

Introduction: Waterhouse-Friderichsen syndrome, due to bilateral adrenal haemorrhage (BAH), is a rare but life-threatening cause of acute adrenal insufficiency, often seen as a complication of overwhelming sepsis. This report aims to emphasise the importance of having a high clinical suspicion of adrenal insufficiency in unwell patients, carrying out relevant investigations, and recognising those at risk of Waterhouse-Friderichsen syndrome. In this report, we investigate the currently understood pathophysiology of BAH in relation to sepsis and laboratory and radiological findings to support this diagnosis. We will review a case study to consider if diagnosis of Waterhouse-Friderichsen syndrome is appropriate, whilst considering alternative diagnoses and management of these patients. Case Presentation: We discuss a young female re-presenting to the emergency department on multiple occasions, within 6 months of discharge from the intensive care unit with severe septic shock due to Escherichia coli bacteraemia of urinary source. On her third re-presentation, she complained of vomiting, abdominal pain, fever, and dysuria and was managed for recurrent urinary tract infection. Due to ongoing vomiting, she had further investigations, which highlighted a low morning cortisol result of 21 nmol/L. She had an inadequate cortisol response to a short Synacthen test, indicating adrenal insufficiency. Conclusion: Based on her previous admission with septic shock, and the understood pathophysiology of BAH, this may be suggestive of a case of Waterhouse-Friderichsen syndrome.