[Dyspnea and skin rash in a 49-year-old male patient]. / Dyspnoe und Hautausschlag bei einem 49-jährigen Patienten.

We report on the case of a 49-year-old man who presented with increasing dyspnea and a skin rash. The community-acquired pneumonia was initially treated with broad spectrum antibiotics. The patient's respiratory condition rapidly worsened and the clinical picture of Waterhouse-Friderichsen syndrome developed with disseminated intravasal coagulopathy and necrosis of the toes. An infection with Capnocytophaga canimorsus, which had been caused by an initially unmentioned dog bite was confirmed. In view of the fulminant course and the high risk of operative treatment of the ubiquitous necroses in all limbs, a joint decision for deescalation of therapy was made together with relatives. The patient died 14 days after admission to hospital.

A rare case of Waterhouse-Friderichsen syndrome caused by Capnocytophaga canimorsus in an immunocompetent patient.

A 53-year-old Caucasian male with hypertension and active tobacco abuse presented to a community hospital with a 2-day history of vague abdominal pain, myalgia and increased lethargy after being bitten on his right hand by the family dog while camping just 3 days prior to symptom onset. He expired within 90 min upon arrival to our intensive care unit. Pre-mortem blood cultures grew a fastidious Gram-negative aerobic rod that was identified as Capnocytophaga canimorsus. Autopsy findings showed multi-organ disseminated intravascular coagulopathy with microthrombi along with bilateral adrenal hemorrhage and necrosis of the adrenal glands consistent with Waterhouse-Friderichsen syndrome. This case contributes to the medical literature as a rare presentation of Capnocytophaga canimorsus infection in an otherwise immunocompetent patient and stresses the importance of a thorough history taking and physical examination by clinicians along with prompt administration of appropriate antibiotics.

Waterhouse Friderichsen syndrome complicating fulminant Enterobacter cloacae sepsis in a preterm infant: the unresolved issue of corticosteroids.

Bilateral adrenal hemorrhage can complicate severe sepsis in the neonate and is most commonly attributed to meningococcal disease; however, it can be caused by other etiologic agents as well. We report herein a fatal case of Enterobacter cloacae sepsis in a preterm infant, resulting in massive adrenal hemorrhages. This is the first documented case of adrenal hemorrhage following infection with this pathogen.

A unique fatal case of Waterhouse-Friderichsen syndrome caused by Proteus mirabilis in an immunocompetent subject: Case report and literature analysis.

INTRODUCTION: The Waterhouse-Friderichsen syndrome (WFS), also known as purpura fulminans, is a potentially lethal condition described as acute hemorrhagic necrosis of the adrenal glands. It is often caused by infection. Classically, Neisseriae meningitidis represents the main microorganism related to WFS, although, infrequently, also other infectious agents are reported as a possible etiologic agent. The authors report the first case of death due to Proteus mirabilis infection, with postmortem evidence of WFS. PATIENT CONCERNS: After a facial trauma that provoked a wound on the nose, the subject, a healthy 40-years old man, was conducted to the local hospital (in Sicily, Italy) after the primary care he was discharged. Subsequently, after 2 days of general malaise, he returned to the hospital due to the worsening of the clinical condition. During the hospitalization, hypotension, and neurological impairment appeared; the laboratory analysis showed leukocytosis and the alteration of renal, hepatic and coagulative parameters. Microbiological blood analysis resulted positive for a P mirabilis infection. DIAGNOSIS: Multiorgan failure (MOF) with disseminated intravascular coagulation (DIC) due to sepsis was diagnosed. INTERVENTIONS: The practitioners administered intensive support, antibiotic therapy, antithrombin III, vitamin K, and plasma. OUTCOMES: After 3 days the subject died. The autopsy and the microscopic investigation were performed revealing, also, the adrenal diffuse micronodular hyperplasia associated with a cortico-medullary hemorrhagic apoplexy. CONCLUSION: To our knowledge, this is the first case of MOF with WFS due to P mirabilis infection. This case report suggests that P mirabilis should be added to the list of unusual bacteria causing WFS. Furthermore, it supports the theory that any bacterium which causes DIC may cause adrenal hemorrhage and should suggest to clinicians the importance to consider a potential adrenal involvement in every patient with sepsis and DIC.

A rare case of Waterhouse- Friderichsen syndrome during primary Varicella zoster infection.

Primary Varicella zoster virus infection in adults is associated with a higher risk of complications when compared with the benign disease course of primary infection during childhood. We present a rare complication of adult primary Varicella zoster in the form of acute, irreversible adrenal insufficiency due to bilateral adrenal haemorrhage, which is also known as the WaterhouseFriderichsensyndrome.

Apparent meningococcemia: clinical features of disease due to Haemophilus influenzae and Neisseria meningitidis.

To determine the etiology of apparent meningococcemia, all cases of sepsis with coagulopathy, purpura, and/or adrenal hemorrhage (Waterhouse-Friderichsen syndrome) with and without shock occurring over a 12-year period were reviewed. A total of 42 cases were identified; 30 cases were caused by Neisseria meningitidis and 12 cases were caused by Haemophilus influenzae. Compared with patients with disease caused by H influenzae, patients with meningococcal disease were older, more often male, more often contracted the disease in winter-spring, and had a longer duration of antecedent symptoms; however, none of these differences was statistically significant. All patients were febrile (greater than 38 degrees C) and appeared toxic. Similar proportions in each group had shock and disseminated intravascular coagulopathy at the time of admission. Ten of 12 patients with H influenzae infection compared with 15/30 (P less than .05) with meningococcal infection were lethargic or comatose at the time of admission. Nine of 12 patients with H influenzae infection died compared with 5/30 with meningococcal disease (P less than .005); the mean time from onset of symptoms to death with H influenzae infection (20.7 +/- 11.4 [SE] hours) was significantly shorter (P less than .05) than with meningococcal infection (120 +/- 74.4 hours). Children with clinical signs of sepsis and with purpura, petechiae, or coagulopathy may have N meningitidis or H influenzae as etiologic agents. Initial antibiotic therapy should be directed against these pathogens.

Overwhelming post-splenectomy infection with Plesiomonas shigelloides in a patient cured of Hodgkin's disease. A case report.

The immune deficiencies of Hodgkin's disease persist to some degree even after the patients are clinically cured; these may be amplified by loss of splenic immunologic functions after staging laparotomy and splenectomy. The authors submit a case report wherein a bacterium of relatively low virulence, Plesiomonas shigelloides, was associated with a rapidly fulminant septicemia, disseminated intravascular coagulation, Waterhouse-Friderichsen syndrome, and death in a splenectomized patient free of Hodgkin's disease for approximately five years. This emphasizes the need for prolonged observation, rapid diagnosis, and aggressive intervention in immunocompromised patients, especially those supposedly cured of previous hematologic malignancy.

Waterhouse-Friderichsen syndrome caused by a DF-2 bacterium in a splenectomised patient.

A case of Waterhouse-Friderichsen syndrome associated with septicaemia caused by a DF-2 group bacterium (dysgonic fermenter--type 2--Atlanta classification) is presented. Attention is drawn to the relation of DF-2 group septicaemias to dog bites (or contact) and impaired host defence after splenectomy.

Fatal pneumococcal septicemia in a patient with a connective tissue disease.

Fulminant pneumococcal sepsis is a rare but life-threatening illness usually occurring in patients with known splenic absence (postsplenectomy) or dysfunction (sickle cell anemia). Several medical illnesses, not typically recognized as being associated with abnormal spleen function, may be complicated by fulminant pneumococcal sepsis. We report a case of fatal pneumococcal sepsis in a patient diagnosed with mixed connective tissue disease who likely had systemic lupus erythematosus and unsuspected splenic fibrosis. Medical illnesses associated with functional asplenia, hematological findings suggesting splenic dysfunction, and confirmatory tests of hyposplenism are discussed.

[A fatal case of overwhelming postsplenectomy infection syndrome developing 10 years after splenectomy].

UNLABELLED: Splenectomized patients are likely to suffer from severe infections, such as sepsis and meningitis. This syndrome is called overwhelming postsplenectomy infection (OPSI) in Europe and America. The course is rapid, the clinical symptoms are serious, and the prognosis is very poor. We treated one adult patient with OPSI syndrome that developed 10 years after splenectomy. CASE: A 26-year-old man had undergone a splenectomy following a traffic accident 10 years previously. On January 7, 1996, he had diarrhea and nausea. On January 10, he became drowsy and presented at our hospital with multiple organ failure. He underwent hemodialysis and plasmapheresis because of acute renal failure and also received immune globulin, antibiotics and prednisolone. However, these medications were not effective. He died 7 hours later. We identified diplococcus on a blood smear, IgG 3 deficiency and a low titer of specific pneumococcal IgG 2 antibody. The autopsy findings included bilateral acute hemorrhagic necrosis of the adrenal glands (Waterhouse-Friderichsen syndrome).

[Morphological characteristics of meningococcemia in children]. / K morfologicheskoi kharakteristike meningokoktsemii u detei

Observations were conducted over 8 children aged 5 months to 3 years and 2 months, in whom the disease developed acutely and was accompanied by collapse. Death occurred within the first 12--36 hours from the onset of the disease. Morphologically, there were revealed haemorrhagic rash, initial phenomena of serous-purulent meningitis, clear-cut disorders of the microcirculation (stasis, thrombosis) in the skin, lungs, myocardium, kidneys. The cause of early death of the children with meningoccaemia turned out to be the Waterhouse-Friderichsen syndrome, the morphological manifestations of the latter being bilateral haemorrhages into the adrenals. In the kidneys capillarothrombosis may develop, which is in accord with the picture of the Sanarelli-Schwartzmann phenomenon, and may lead to the development of acute renal insufficiency with formation of cortical necroses of the kidneys.