Introduction. Bilateral massive adrenal hemorrhage (BMAH) is a rare catastrophic condition that manifests with acute adrenal insufficiency. Death can occur within a few hours or after many days. BMAH in association with fulminant septicemia and sepsis occurring in children and young adults is also known as the Waterhouse-Friderichsen syndrome. Fulminant sepsis associated with purpura is lethal in 40–70% of patients. Case report. The abrupt onset of fever with sore throat occurred in a 20-year old man. Next day in the early morning, he complained of severe symptoms: generalized weakness, shortness of breath and myalgia. Few hours later petechial rash occur. Within 30 hours from first symptoms he died in hospital. On autopsy, there were macroscopic bilateral areas of adrenal hemorrhage. Autopsy also revealed hemorrhage in almost all organs and tissues. Microbiological blood culture and toxicological finding was negative. Discussion. In our case, very high levels of procalcitonin and D-dimer, with all other clinically and autopsy findings, was directing medical examiners that a main cause of death was fulminant bacterial sepsis. Blood culture did not reveal any bacteria, so the cause of BMAH stays uncovered. The bacteria that most often cause fulminant sepsis connected with BMAH and death within 12–24 hours from first symptoms is N. meningitidis. It is very likely that N. meningitidis caused BMAH in our case, but it will stay in domain of speculation.
 Ringkananon U, Khovidhunkit W, Vongthavaravat V, Sridama V, Lalitanantpong S and Snabboon T. Adrenal crisis due to bilateral adrenal hemorrhage in primary antiphospholipid syndrome. J Med Assoc Thai 2005;88(4):534–537
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