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Background: bilateral adrenal hemorrhage can cause adrenal insufficiency. Antiphospholipid syndrome (APS) is considered a rare etiology of bilateral adrenal hemorrhage with a relatively small number of case reports. APS can be secondary to other autoimmune diseases such as SLE in which cardiac manifestations are common. Case presentation: a fifty-four-year-old male presents with left flank pain as a result of unilateral adrenal hemorrhage, a few days later, bilateral hemorrhage is documented in the presence of abnormal coagulation state and other laboratory clues. APS diagnosis was established. Coexisting chest pain accompanied by diffused ST elevation, long QT, slightly high troponin with a high pro-BNP, in addition to echo’s findings such abnormal regional wall abnormality and the absence of pericardial effusion made the case more interesting, differential diagnosis was proposed in accordance. Conclusion: bilateral hemorrhage in APS considered rare.  Requiring a high index of clinical suspicion. Particularly when it is the initial manifestation of APS as in our case.  Underlying autoimmune diseases should be screened actively, especially when other unexplained manifestations are presented.

Bilateral Adrenal Hemorrhage and Coagulation Laboratory Abnormalities: A Case Report of a Man with Enigmatic Clinical Features.