Unilateral adrenal haemorrhage during bridging anticoagulation in primary antiphospholipid syndrome: a case-based review.

Antiphospholipid syndrome (APS) is a major cause of acquired thrombophilia and is frequently associated with recurrent venous thromboembolism requiring long-term anticoagulation. We report a 42-year-old man with primary APS and recurrent pulmonary embolism and deep vein thrombosis who developed acute right upper-quadrant abdominal pain during peri-procedural bridging anticoagulation with enoxaparin. Computed tomography (CT) and magnetic resonance imaging demonstrated acute-to-subacute unilateral right adrenal haemorrhage without evidence of abdominal trauma, malignancy or infection. The patient remained haemodynamically stable and did not develop adrenal insufficiency. This case highlights the complexity of anticoagulation management in high-risk APS patients and emphasises the importance of considering adrenal haemorrhage in APS patients presenting with abdominal pain during anticoagulation modification. A review of previously reported unilateral APS-associated adrenal haemorrhage cases is also presented. Key Points • Unilateral adrenal haemorrhage is a rare manifestation of primary antiphospholipid syndrome. • Bridging anticoagulation may represent a vulnerable period for adrenal haemorrhage in high-risk APS. • Early CT/MRI imaging and assessment of adrenal function are essential. • Conservative management with careful reintroduction of anticoagulation may lead to favourable outcomes.