Bilateral Adrenal Hemorrhage in Systemic Lupus Erythematosus and Antiphospholipid Syndrome: A Review of Mechanisms, Diagnosis, and Clinical Outcomes

Bilateral adrenal hemorrhage (BAH) is an uncommon but potentially fatal cause of adrenal insufficiency, particularly in patients with underlying hypercoagulable disorders. Autoimmune-mediated vasculitis, thrombosis, systemic lupus erythematosus (SLE), and antiphospholipid syndrome (APS) contribute to adrenal vascular compromise, yet literature on this association remains limited. We conducted a structured literature review using PubMed, focusing on articles in English published between 2000 and March 2025 that described BAH in the setting of SLE and/or APS. Search terms included "bilateral adrenal hemorrhage," "systemic lupus erythematosus," "adrenal insufficiency," "antiphospholipid syndrome," and related MeSH terms. Case reports, case series, and observational studies reporting BAH confirmed radiologically or histopathologically were included. The review identified autoimmune vasculitis, APS-related thrombosis, and hypercoagulability as major contributors to BAH. Clinical presentation is often nonspecific, with abdominal pain, hypotension, fever, and adrenal crisis as common features. Computed tomography (CT) remains the preferred initial imaging modality, while magnetic resonance imaging (MRI) offers superior sensitivity for early detection. Management requires prompt glucocorticoid and mineralocorticoid replacement, hemodynamic stabilization, and individualized anticoagulation strategies in APS-associated cases. Prognosis depends on timely diagnosis, correction of adrenal insufficiency, and control of underlying autoimmune activity. BAH in the context of SLE and APS remains a rare but life-threatening entity, and clinicians should maintain a high index of suspicion in autoimmune patients presenting with acute abdominal pain and hemodynamic instability. Early imaging, laboratory confirmation, and multidisciplinary management are essential for improving survival and long-term outcomes.