Adrenal gland and paraganglia
Adrenal insufficiency
Waterhouse-Friderichsen syndrome

Reviewer: Nat Pernick, M.D. (see Authors page)

Revised: 1 March 2016, last major update February 2005

Copyright: (c) 2002-2016,, Inc.

PubMed Search: Waterhouse-Friderichsen syndrome
Cite this page: Waterhouse-Friderichsen syndrome. website. Accessed October 24th, 2016.
Definition / General
  • Hemorrhagic necrosis of adrenal glands, usually due to bacteremia, classically Neisseria meningitides; also Pseudomonas aeruginosa, pneumococci, staphylococcus and historically Haemophilus influenzae
  • Less common causes are burns, cardiac failure, hypothermia and birth trauma
Clinical Features
  • More common in children, particularly before age 2 years
  • Usually bilateral; newborns may have unilateral hemorrhage, more commonly in right adrenal gland
  • Symptoms: shock, disseminated intravascular coagulation and adrenal insufficiency; the shock may cause the hemorrhage
  • Meningococcemia (Arch Pathol Lab Med 1977;101:6)
Case Reports
  • Treat underlying infection with antibiotics
  • Also cortisol, electrolytes
  • Must detect and treat quickly
Gross Description
  • Glands are enlarged and hemorrhagic with extensive cortical and medullary necrosis
Gross Images

Images hosted on PathOut server:

Fatal meningococcemia in 10 month old boy, courtesy Dr. Eric L. Vey, Erie County Coroner Officer, Erie, PA (USA):

Adrenal glands in situ

Normal (top) and hemorrhagic (bottom) adrenal glands

Micro Description
  • Hemorrhage, necrosis, fibrin deposition, neutrophilic infiltration of medulla and cortex
  • Zona glomerulosa cells may be spared
Micro Images

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Due to Capnocytophaga canimorsus

Differential Diagnosis
  • Central adrenal vein thrombosis