case_images: PMC6098898_01
case_images: Contrast-enhanced abdominal CT demonstrates haemorrhage of the swollen adrenal glands (arrow) and status after splenectomy (a). There is fluid collection in the perirenal space (arrowheads), and the corticomedullary differentiation of the kidneys is lost (b).
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case_images: PMC6098898_01_CRIID2018-3870640.001.jpg
case_images: fig1
case_images: The corticomedullary differentiation of the kidney was absent (Figure 1(b)). The adrenal glands were swollen on both sides, suggesting haemorrhage (Figure 1(a)).
case_images: Cranial CT reveals hyperdense sedimentations (Hounsfield unit (HU) 23) in both posterior lateral ventricles, suggesting haemorrhage or pus.
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case_images: PMC6098898_01_CRIID2018-3870640.002.jpg
case_images: fig2
case_images: In a subsequent CT scan of the head, a hyperdense sediment in both lateral ventricles was observed with a Hounsfield unit (HU) of 23, also suggesting intraventricular pus or haemorrhage (Figure 2).
case_images: Necrosis of the left hand.
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case_images: PMC6098898_01_CRIID2018-3870640.003.jpg
case_images: fig3
case_images: Despite forced treatment in the ICU, including vancomycin and meropenem, the patient's condition continued to deteriorate, accompanied by liver failure and severe necrosis in both legs and the left arm (Figure 3).
case_images: Haemorrhagic necrosis of the adrenal gland and complete necrosis of the adrenal gland. The different zones of the adrenal cortex cannot be clearly distinguished. Especially the cortex shows extensive haemorrhage (arrow). The cells are ill-defined and intermingled with fibrin exudation, showing nuclear shadows (insert, double arrow). The cellular compartment of the adrenal medulla is necrotic with intermingled fibrin exudation (star) (haematoxylin and eosin, original magnification 4x insert, original magnification 20x).
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case_images: PMC6098898_01_CRIID2018-3870640.004.jpg
case_images: fig4
case_images: Compatible with the morphological presentation of the adrenal gland in the CT scan and the macroscopic aspect, the histomorphological findings revealed complete haemorrhagic necrosis of the parenchyma on both sides (Figure 4).
case_images: Dilated vessels, disseminated haemorrhage, and oedema of the brain. The brain shows ubiquitously oedema with loosened parenchyma. The vessels are dilated (arrows). Diffuse erythrocyte extravasation is shown (double arrows; haematoxylin and eosin, original magnification 4x insert, original magnification 20x).
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case_images: PMC6098898_01_CRIID2018-3870640.005.jpg
case_images: fig5
case_images: The macroscopic and microscopic neuropathological examination of the brain and tissue samples showed dilated vessels, ubiquitously disseminated haemorrhage, and oedema (Figure 5).
case_images: Complete necrosis of the lung with extensive haemorrhage and absceding bronchopneumonia. (a) Completely necrotic lung parenchyma with extensive intra-alveolar haemorrhage. The lung parenchyma is visible as a shadow. (b) An intra-alveolar infiltration by neutrophilic granulocytes (double arrows), focally with abscess formation (haematoxylin and eosin, original magnification 4x insert, original magnification 20x).
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case_images: PMC6098898_01_CRIID2018-3870640.006.jpg
case_images: fig6
case_images: According to the performed ventilation, the lungs had signs of an acute respiratory distress syndrome (ARDS), and consistent with the pulmonary infiltrations visible on the chest X-ray, an ascending bronchopneumonia with accompanying fibrinous pleuritis was observed (Figure 6).