A 59 year old women presented to the accident and emergency department with tachycardia and hypotension following a one day history of feeling unwell. She was peripherally shutdown, cyanosed, hypoxic, had a purpuric rash and numbness to her fingers. CT scan revealed bilateral adrenal haemorrhage consistent with Waterhouse-Friderichsen syndrome. This was further confirmed with a Short synacthen test(SST) showing a peak 30 minute cortisol of 102 nmol/l. She was commenced on oral dexamethasone. As a further complication she was found to have IgM paraprotein with a large bone marrow infiltration consistent with lymphoplasmacytic lymphoma. She commenced chemotherapy but without sufficient steroid cover developed an Addisonion crisis. A repeat short synacthen test several weeks later revealed a 30 minute cortisol response of 60 nmol/l. Hydrocortisone replacement therapy was commenced. One year later, she underwent a long synacthen test to assess for recovery of adrenal function. This revealed a suboptimal response with a peak of 439 nmol/l. She was recommenced onto Hydrocortisone replacement therapy. She was haemodynamically unstable for three weeks requiring intensive therapy with respiratory, vascular and renal support. The consequences of her severe septicaemia lead to bilateral adrenal haemorrhage and digital amputation as a result of peripheral digital necrosis. Meningiococal and other bacterial screens proved negative, while a vaginal swab isolated HSV-1 infection. This is the first report of adrenal haemorrhage in association with HSV infection. There have been 2 case reposts of adrenal insufficiency in the context of HSV infection but they were both in the newborn. None of these cases reported adrenal haemorrhage as the cause of the adrenal failure. This case illustrates the importance of adrenal assessment in the context of disseminated HSV infection.
Declaration of interest: There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.
Funding: No specific grant from any funding agency in the public, commercial or not-for-profit sector.