Case Presentation: A 24-year-old male with a six-year history of systemic lupus erythematosus (SLE) presented to the emergency department with acute, severe left-sided abdominal pain accompanied by nausea and vomiting. His medical history included lupus nephritis, but his disease had been poorly managed due to noncompliance and inadequate follow-up. He denied previous similar episodes.On physical examination, the patient was afebrile but exhibited mild tachycardia and tenderness over the left flank. Laboratory findings revealed elevated activated partial thromboplastin time (APTT), mild anemia, and increased lactate dehydrogenase (LDH). Urinalysis demonstrated proteinuria, consistent with active lupus nephritis.Imaging with computed tomography (CT) revealed left renal vein thrombosis and a 22 × 17 mm adrenal hemorrhage with thickened adrenal tissue. Magnetic resonance imaging (MRI) confirmed the hemorrhage as subacute and detected thrombus extension into the inferior vena cava.The patient was admitted to the intensive care unit for monitoring and anticoagulation therapy, initiated with a heparin infusion followed by transition to warfarin. Due to the hemorrhage’s small size and stability, surgical intervention was unnecessary however anticoagulation was continued weighing risk-benefit ratio Pain control was achieved with intravenous analgesics, and corticosteroids were started for lupus nephritis. Patient was started on immunosuppressive therapy with mycophenolate mofetil and prednisone. Regular imaging follow-up was arranged to monitor resolution of the thrombus and hemorrhage.
Discussion: Renal vein thrombosis (RVT) is a rare but recognized complication of systemic lupus erythematosus (SLE), particularly when associated with antiphospholipid antibody syndrome (APS) or nephrotic syndrome. The elevated APTT and clinical presentation in this case strongly implicated APS as the underlying etiology.Adrenal hemorrhage, while uncommon in adults, may occur secondary to hypercoagulable states and venous congestion from RVT. The left adrenal gland’s unique venous anatomy, with drainage into the left renal vein, predisposes it to such complications. Advanced imaging, particularly MRI, is essential for confirming the hemorrhage and ruling out other diagnoses such as adrenal tumors or metastases.A multidisciplinary approach involving hematology, nephrology, and critical care specialists facilitated timely diagnosis and management. The decision to forgo surgical intervention underscored the importance of individualized care based on the stability of the hemorrhage and patient-specific factors.
Conclusions: This case emphasizes the importance of considering adrenal hemorrhage in the differential diagnosis of abdominal pain in patients with renal vein thrombosis, particularly in the setting of hypercoagulable conditions such as APS and SLE. Timely diagnosis and a multidisciplinary approach can prevent complications and mitigate morbidity and mortality.