Adrenal Haemorrhage in the Context of Acute Systemic Illness: Three Cases With Diverse Clinical Presentations

Adrenal haemorrhage (AH) is uncommon and often underrecognized and may complicate severe systemic stress, infection, or coagulopathy. Prompt diagnosis is essential to exclude adrenal insufficiency and adrenal neoplasms. Three cases of AH occurring in varied clinical settings describe diagnostic approaches, management, and outcomes and draw insights for clinicians. Case 1 is a patient in septic shock hospitalised in the ICU who developed bilateral AH (Waterhouse-Friderichsen syndrome). Case 2 is about a patient admitted for chest pain, fall, and suspected infective exacerbation of chronic obstructive pulmonary disease (COPD), later found to have unilateral AH in the context of pulmonary embolism. Case 3 indicates a patient with essential thrombocythaemia and hypertension, presenting with acute abdomen after a flu-like illness, found to have a left adrenal lesion with features of haemorrhage within a lipid-rich adenoma. In all three cases, adrenal insufficiency was assessed; in two cases, steroid therapy was administered, while in one (Case 2), it was not required. Repeat imaging over months showed resolution or stability without malignant transformation. These three cases underscore the heterogeneity of AH presentations, the need for prompt endocrine evaluation, imaging follow-up, and multidisciplinary care. Recognition in atypical settings (e.g., sepsis, respiratory infection, and haematological disease) is key to preventing adrenal crisis and guiding management.