Review Question - QID 210065

This patient is presenting with meningitis which has progressed to hemorrhagic adrenalitis (Waterhouse-Friderichsen syndrome).

Meningitis from Neisseria meningitidis typically presents with fever, photophobia, and meningeal symptoms (neck stiffness and Kernig/Brudzinski sign). If untreated, it can disseminate and cause hemorrhagic adrenalitis (Waterhouse-Friderichsen syndrome). Hemorrhagic adrenalitis presents with sudden vasomotor collapse (causing hypotension and tachycardia) and a characteristic skin rash (purpura fulminans) in a patient who previously had signs and symptoms of meningitis. Treatment involves aggressive fluid resuscitation, steroids, and antibiotics. Vasopressors will likely be needed during resuscitation.

Badawy et al. review the evidence regarding the diagnosis and treatment of patients with adrenal hemorrhage. They discuss how this disease often occurs secondary to other infections or neoplasms. They recommend having a high index of suspicion for this disorder.

Figure/Illustration A is a clinical photograph demonstrating a hemorrhagic/violaceous rash (red circles). This rash is classically seen in Waterhouse-Friderichsen syndrome.

Incorrect Answers:
Answer 1: Congenital clotting disorder such as factor V leiden could present with thrombosis such as a deep vein thrombosis or pulmonary embolism. It is managed with anticoagulation.

Answer 2: Disseminated intravascular coagulation classically presents with bleeding from IV sites and schistocytes secondary to activation of the clotting cascade. Patients are often critically ill and experience both hemorrhage and thrombosis. This diagnosis is certainly plausible in this patient and there is significant overlap between these conditions.

Answer 4: Severe sepsis may be supported with qSOFA criteria. It would not present with sudden vasomotor collapse in a patient with meningitis. Treatment is with broad spectrum intravenous antibiotics. Note that this patient has septic shock rather than severe sepsis given his ongoing hypotension and tachycardia despite fluid boluses.

Answer 5: Meningitis presents with neck stiffness, fever, and photophobia. Though this patient initially presented with meningitis, his condition has progressed to hemorrhagic adrenalitis. While bacterial meningitis is likely present, it is unlikely this patient has a viral meningitis.

Bullet Summary:
Hemorrhagic adrenalitis presents with sudden vasomotor collapse and a characteristic skin rash in a patient who previously had signs and symptoms of meningitis.