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Waterhouse-Friderichsen syndrome

Waterhouse-Friderichsen syndrome

Fulminant meningococcemia - Waterhouse-Friderichsen syndrome; Fulminant meningococcal sepsis - Waterhouse-Friderichsen syndrome; Hemorrhagic adrenalitis


Waterhouse-Friderichsen syndrome (WFS) is a group of symptoms caused when the adrenal glands fail to function normally. This occurs as a result of bleeding into the glands.



The adrenal glands are two triangle-shaped glands. One gland is located on top of each kidney. The adrenal glands produce and release different hormones that the body needs to function normally. The adrenal glands can be affected by many diseases, such as infections like WFS.

WFS is caused by severe infection with meningococcus bacteria or other bacteria such as:

  • Group B streptococcus
  • Pseudomonas aeruginosa
  • Streptococcus pneumoniae
  • Staphylococcus aureus




Symptoms occur suddenly. They are due to the bacteria growing in number inside the body. Symptoms include:

  • Fever and chills
  • Joint and muscle pain
  • Headache
  • Vomiting

Infection with bacteria causes bleeding throughout the body, which causes:

  • A rash throughout the body
  • Disseminated intravascular coagulation in which small blood clots cut off blood supply to the organs
  • Septic shock

Bleeding into the adrenal glands causes not enough adrenal hormones to be produced. This is called adrenal crisis, and it leads to symptoms such as:

  • Dizziness, weakness
  • Very low blood pressure
  • Very fast heart rate
  • Confusion or coma


Exams and Tests


The health care provider will perform a physical exam and ask about your symptoms.

Blood tests will be done to confirm a bacterial infection. Tests may include:

  • Blood culture
  • Complete blood count with differential
  • Blood clotting studies

If the provider suspects the infection is caused by meningococcus bacteria, other tests that may be done include:

  • Lumbar puncture to get a sample of spinal fluid for culture
  • Skin biopsy and Gram stain
  • Urine analysis

Tests that may be ordered to help diagnose acute adrenal crisis include:

  • ACTH (cosyntropin) stimulation test
  • Cortisol blood test
  • Blood sugar
  • Potassium blood test
  • Sodium blood test
  • Blood pH test




Antibiotics are started right away to treat the bacterial infection. Glucocorticoid medicines will also be given to treat adrenal gland insufficiency. Supportive treatments will be needed for other symptoms.


Outlook (Prognosis)


WFS is fatal unless treatment for the bacterial infection is started right away and glucocorticoid drugs are given.




To prevent WFS caused by meningococcal bacteria, a vaccine is available.




Stephens DS. Neisseria meningitides. In: Bennett JE, Dolin R, Blaser MJ, eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 9th ed. Philadelphia, PA: Elsevier; 2020:chap 211.

Newell-Price JDC, Auchus RJ. The adrenal cortex. In: Melmed S, Auchus RJ, Goldfine AB, Koenig RJ, Rosen CJ, eds. Williams Textbook of Endocrinology. 14th ed. Philadelphia, PA: Elsevier; 2020:chap 15.

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  • Meningococcal lesions on the back

    Meningococcal lesions on the back


  • Adrenal gland hormone secretion

    Adrenal gland hormone secretion


    • Meningococcal lesions on the back

      Meningococcal lesions on the back


    • Adrenal gland hormone secretion

      Adrenal gland hormone secretion


    A Closer Look


      Talking to your MD


        Self Care


          Tests for Waterhouse-Friderichsen syndrome


            Review Date: 9/1/2021

            Reviewed By: Jatin M. Vyas, MD, PhD, Associate Professor in Medicine, Harvard Medical School; Associate in Medicine, Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, MA. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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