Autoimmune Adrenalitis in Systemic Lupus Erythematosus: Identifying a Rare Endocrine Complication

Primary adrenal insufficiency (PAI) secondary to nonhemorrhagic adrenalitis is an extremely rare but potentially life-threatening endocrine manifestation in patients with systemic lupus erythematosus (SLE). We report the case of a 51-year-old man with longstanding SLE and antiphospholipid syndrome (APS) who presented with an adrenal crisis, characterized by fatigue, weight loss, vomiting, and abdominal pain. Laboratory evaluation revealed hypotension, metabolic acidosis, elevated adrenocorticotropic hormone (ACTH), and low serum cortisol, confirming the diagnosis of PAI. Abdominal CT imaging demonstrated bilateral adrenal gland enlargement with periadrenal fat stranding, consistent with nonhemorrhagic adrenalitis. The patient showed rapid clinical improvement following initiation of stress-dose corticosteroids and was subsequently discharged on lifelong glucocorticoid and mineralocorticoid replacement therapy. This case emphasizes the importance of maintaining a high clinical suspicion for adrenal insufficiency in patients with SLE who present with nonspecific symptoms, such as fatigue, vomiting, and abdominal pain, that may be mistakenly attributed to a typical lupus flare, even when classic signs of adrenal hemorrhage or typical laboratory abnormalities are absent. Early diagnosis and treatment are critical to prevent life-threatening adrenal crises in this patient population.