Abstract / Summary
Adrenal hemorrhage is an uncommon manifestation of antiphospholipid syndrome (APS) and may result from adrenal venous or microvascular thrombosis followed by hemorrhagic infarction. Adrenal insufficiency is more commonly associated with bilateral adrenal involvement, making clinically significant dysfunction with predominantly unilateral hemorrhage unusual. A 35-year-old Palestinian man presented with a febrile illness, abdominal pain, progressive fatigue, anorexia, weight loss, and generalized weakness. Computed tomography demonstrated a large right adrenal hematoma, while biochemical evaluation showed severe hyponatremia and a low serum cortisol concentration of 2.8 µg/dL, raising concern for adrenal insufficiency. Laboratory testing also revealed thrombocytopenia and markedly prolonged activated partial thromboplastin time (aPTT). A mixing study failed to correct the aPTT, suggesting an inhibitor, and lupus anticoagulant testing was positive. Subsequent testing demonstrated high-titer anticardiolipin and anti-β2-glycoprotein I antibodies, establishing a high-risk triple-positive antiphospholipid antibody profile. Hematology later favored APS-associated thrombotic adrenal injury, and therapeutic anticoagulation with enoxaparin followed by warfarin was initiated. Hydrocortisone and fludrocortisone were subsequently prescribed for adrenal insufficiency. During follow-up, the patient showed progressive clinical, biochemical, and radiological improvement, with normalization of renal function and electrolytes and marked reduction in the adrenal hematoma. APS-associated adrenal hemorrhage may represent thrombotic adrenal vascular injury despite its hemorrhagic appearance. In patients with unexplained adrenal hemorrhage, thrombocytopenia, adrenal dysfunction, and marked aPTT prolongation, lupus anticoagulant and antiphospholipid antibody testing should be considered. Early recognition of adrenal insufficiency and multidisciplinary management are important in this rare presentation. Not applicable.