ABSTRACT
SESSION TITLE: Emergency Endocrine Disorders SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Spontaneous bilateral adrenal hemorrhage (BAH) resulting in adrenal crisis is a rare, but serious condition that can easily be missed as patients may present with non-specific symptoms (weakness, fatigue, nausea, vomiting, dizziness). It can escalate to hemodynamic instability in the setting of adrenal crisis. The most common cause is meningococcal disease, other causes include trauma, septicemia, and coagulopathies. Without treatment it is fatal and carries a high mortality rate of 15%;Waterhouse-Friderichsen syndrome has been reported with 55-60% mortality. Here, we describe a case of a patient with a history of myelodysplastic syndrome (MDS) who presented with multiple readmissions with a septic shock picture with unknown source of infection and was finally diagnosed with bilateral adrenal hemorrhage causing adrenal crisis. CASE PRESENTATION: An 85-year old independently living man with past medical history of MDS and hypertension presented after a syncopal episode at home with altered mental status. Treatment was initiated for a urinary tract infection which progressed to shock. His labs were notable for leukocytosis in the 40,000s and a platelet count in the 30s. He was found to have BAH on imaging. He was started on broad-spectrum antibiotics, vasopressors and stress-dose steroids with improvement in his condition and eventually discharged home. He was readmitted to the ICU twice within a month for shock, each time with a negative infection workup, as he had been discharged home without steroids to follow up with an endocrinologist. After his third readmission, he was discharged on steroids and he did not have any further readmissions to the hospital. Exhaustive investigations were made into possible infectious causes of his BAH as well as possible vasculitis and hematologic causes. It was determined to likely be in the setting of thrombocytopenia brought on by his MDS. DISCUSSION: Thrombocytopenia is a rare cause of BAH and adrenal crisis. Review of literature mostly describes cases of heparin-induced thrombocytopenia, a few cases of COVID19 and vaccine-induced immune thrombocytopenia after the COVID vaccine. In our patient, it was thought that MDS predisposed him to spontaneous BAH and subsequently adrenal crisis, which has only been described once before in the literature. Stress dose steroids are commonly used in the ICU for relative adrenal insufficiency. Due to the acuity of his condition and concern for relative adrenal insufficiency, our patient was tapered off steroids and discharged home with endocrinology follow up which led to his frequent readmissions as his underlying problem was not addressed. CONCLUSIONS: Adrenal insufficiency is rare and may be difficult to diagnose especially in the acute setting. It is important to recognize and treat adrenal crisis as it has a high mortality rate. MDS is a rare cause. Reference #1: Manganaro L, Al Ansari N, Barchetti F, et al. Bilateral Adrenal Hemorrhage in a Patient with Myelodysplastic Syndrome: Value of MRI in the Differential Diagnosis. Case Reports in Radiology. 2013;2013:e479836. doi:10.1155/2013/479836 Reference #2: Rosenberger LH, Smith PW, Sawyer RG, Hanks JB, Adams RB, Hedrick TL. Bilateral adrenal hemorrhage: the unrecognized cause of hemodynamic collapse associated with heparin-induced thrombocytopenia. Crit Care Med. 2011;39(4):833-838. doi:10.1097/CCM.0b013e318206d0eb Reference #3: Fatima Z, Tariq U, Khan A, et al. A Rare Case of Bilateral Adrenal Hemorrhage. Cureus. 2018;10(6):e2830. Published 2018 Jun 18. doi:10.7759/cureus.2830 DISCLOSURES: No relevant relationships by Robbert Crusio No relevant relationships by Justyna Michalik No relevant relationships by Aditya Saholi
ABSTRACT
BACKGROUND: Capnocytophaga canimorsus, a Gram-negative rod, belongs to the Flavobacteriaceae family and colonizes the oropharynx of dogs and cats. Infections with C. canimorsus are rare and can induce a systemic infection with a severe course of the disease. So far, only five case reports of C. canimorsus infections associated with Waterhouse-Friderichsen Syndrome (WFS) have been reported with only two of the patients having a history of splenectomy. CASE PRESENTATION: Here, we report a fatal case of WFS due to C. canimorsus bacteremia and mycetal superinfection in a 61-year-old female asplenic patient. Despite extensive therapy including mechanical ventilation, antibiotic coverage with meropenem, systemic corticosteroids medication, vasopressor therapy, continuous renal replacement therapy, therapeutic plasma exchange, multiple transfusions of blood products and implantation of a veno-arterial extracorporeal membrane oxygenation the patient died 10 days after a dog bite. The autopsy showed bilateral hemorrhagic necrosis of the adrenal cortex and septic embolism to heart, kidneys, and liver. Diagnosis of C. canimorsus was prolonged due to the fastidious growth of the bacteria. CONCLUSIONS: The occurrence of a severe sepsis after dog bite should always urge the attending physician to consider C. canimorsus as the disease-causing pathogen. A therapeutic regimen covering C. canimorsus such as aminopenicillins or carbapenems should be chosen. However, despite maximum therapy, the prognosis of C. canimorsus-induced septic shock remains very poor. Asplenic or otherwise immunocompromised patients are at higher risk for a severe course of disease and should avoid exposure to dogs and cats and consider antibiotic prophylaxis after animal bite.