A CURIOUS CASE OF SPONTANEOUS WATERHOUSE-FRIDERICHSEN SYNDROME A Vaughn-Allen MD, M Fashho MD Department of Medicine, Louisiana State University Health Sciences Center, Lafayette, LA INTRODUCTION: Waterhouse-Friderichsen syndrome is uncommon, but it is especially rare when it is acquired in the absence of bacterial sepsis, i.e. fulminant meningococcemia. However, other causes can include anticoagulants, antiphospholipid syndrome, physiologic stress, tumor metastasis, and postoperative hemorrhage. This is a case of spontaneous bilateral Waterhouse- Friderichsen syndrome in a post-knee replacement patient on Eliquis. CASE: A 59 y/o female presented with fevers, hypoglycemia, and hypotension complaining of shortness of breath, nausea, abdominal pain, headache, myalgia, fatigue, and dizziness. Per chart review, patient recently had left knee replacement approximately one week prior to presentation and was placed on Eliquis for deep venous thrombosis prophylaxis. Two days prior to presentation, she was seen for right upper quadrant abdominal pain and hyperglycemia. Computed Tomography (CT) of the abdomen showed minimal non-specific stranding surrounding her adrenal glands. She refused treatment was discharged with instructions to return if symptoms worsened. On current admission, repeat CT of the abdomen and pelvis revealed new bilateral adrenal hematomas. The patient’s family denied recent trauma or falls. No abdominal or retroperitoneal bruising was noted on physical exam. Other significant labs revealed leukocytosis, lactic acidosis, acute kidney injury, and thrombocytopenia. Patient was initiated on intravenous fluids (IV), vasopressors, and antibiotics for possible septic shock secondary to a urinary tract infection. Anticoagulation was held and patient was started on IV hydrocortisone 100mg every eight hours out of concern for adrenal insufficiency secondary to spontaneous adrenal hemorrhages. Eventually, the patient did become more alert and oriented. Antibiotics were discontinued as final blood and urine cultures were negative. She remained hemodynamically stable and was able to be downgraded from the intensive care unit. She was discharged home on oral hydrocortisone 25mg daily. DISCUSSION: In this patient, it was highly suspected that Eliquis was the culprit of her bilateral adrenal hemorrhages in the absence of trauma or infection. It is important to be able to recognize that symptoms in these patients are relatively non-specific and can often mimic septic shock. However, with appropriate and timely management, patients often recover – possibly without even requiring long term glucocorticoid and mineralocorticoid replacement.
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