A Rare Presentation of Probable Catastrophic Antiphospholipid Syndrome with Bilateral Adrenal Haemorrhage

Background: Catastrophic antiphospholipid syndrome (CAPS), a rare thrombotic manifestation of antiphospholipid syndrome (APS), carries high mortality. Bilateral adrenal hemorrhage (BAH), an unusual com-plication of APS, is seldom reported. This case highlights a rare presen-tation of bilateral adrenal haemorrhage due to probable CAPS second-ary to systemic lupus erythematosus (SLE). Methods: A 57-year-old diabetic female presented with hypovolemic shock, abdominal pain, and vomiting. Clinical evaluation, imaging (CECT abdomen), and laboratory investigations (anti-β2GP1 IgG, lupus anticoagulant, anticardiolipin antibodies) were conducted. Secondary causes like sepsis, trauma, and coagulopathies were excluded. SLE workup included ANA and anti-dsDNA testing. Results: CECT revealed bilateral adrenal hemorrhage. Persistent posi-tivity for antiphospholipid antibodies confirmed APS. Elevated ANA (1:100) and anti-dsDNA suggested underlying SLE, despite absent typi-cal symptoms. Serum cortisol (9.2 μg/dL) and ACTH (180 pg/mL) indi-cated evolving adrenal insufficiency. The patient received methylpred-nisolone pulses, IVIG, anticoagulants, and immunosuppressants (MMF), achieving rapid stabilization without mineralocorticoid replacement. Conclusion: This case underscores BAH as a rare but critical manifesta-tion of CAPS, particularly in SLE-associated APS. Early diagnosis via antibody testing and imaging, combined with aggressive immunosup-pression and anticoagulation, improves outcomes. The absence of clas-sic SLE symptoms highlights the need for heightened clinical suspicion in atypical presentations. This report enriches the limited literature on CAPS-related BAH and reinforces multidisciplinary management in thrombotic-autoimmune syndromes.