Adrenal hemorrhage and myocarditis in a patient with systemic lupus erythematosus: A case report and literature review.

Bilateral adrenal hemorrhage is a rare and serious complication that might affect patients with concomitant systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). However, this study presents a rare case of SLE without APS that developed bilateral adrenal hemorrhage, causing adrenal insufficiency and later complicated by lupus myocarditis, resulting in rapid deterioration and death. A 35-year-old female complained of generalized body aches associated with arthralgia, joint swelling, abdominal pain, and fatigue for 2 weeks duration. The clinical course was complicated by seizure, bilateral adrenal hemorrhage, and resultant adrenal insufficiency in addition to pulmonary embolism. High troponin titers and echocardiographic findings of global wall hypokinesia suggested lupus myocarditis. Despite treatment with multiple medications throughout the patient's course of disease, including hydrocortisone, methylprednisolone, and hydroxychloroquine, the patient's condition deteriorated, and she died. Only a few cases of isolated SLE complicated by adrenal hemorrhage were reported during the literature review, with the majority of other cases associated with APS. Notably, no instances of concurrent myocarditis were reported in the reviewed studies. Adrenal hemorrhage may result from heightened arterial or venous pressure, often linked to elevated adrenocorticotropic hormone levels during stress or hypercoagulability. Anticoagulants can increase this risk, while reperfusion injury after hypotensive episodes also contributes. Patients with an SLE flare can develop bilateral adrenal hemorrhage and cause adrenal insufficiency even in the absence of definitive APS. The development of lupus myocarditis in such patients may result in worsened outcomes and potentially death.