Adrenal hemorrhage due to hypercoagulable state mimicking pheochromocytoma

Adrenal insufficiency due to hemorrhagic adrenal infarction is a rare complication of hypercoagulable states. It usually manifests as bilateral adrenal hemorrhage with primary adrenal insufficiency. Here we report a 56-year-old male with known history of autoimmunity on chronic glucocorticoids, who presented with acute abdominal pain and hypertension. Initial imaging and biochemical evaluation was suspicious for a pheochromocytoma. However, subsequently he developed bilateral adrenal hemorrhage with clinical and biochemical evidence of primary adrenal insufficiency. A concurrent massive pulmonary embolism raised a high suspicion for a hypercoagulable state, which was not confirmed by laboratory evaluation, although a thorough evaluation could not be completed. This case highlights the rare occurrence of sequential bilateral adrenal hemorrhage which can be caused by hypercoagulable states, and biochemically mimic a pheochromocytoma.