Adrenal hemorrhage mimicking renal bleed: A rare path to infective endocarditis

Spontaneous adrenal hemorrhage (SAH) is exceedingly rare and diagnostically challenging, often mimicking renal pathology. Its association with infective endocarditis (IE) remains poorly characterized. We report a case of SAH initially misdiagnosed as renal hemorrhage, which unveiled occult, culture-negative infective endocarditis (IE). A 36-year-old woman presented with acute flank pain, anemia, and coagulopathy. Initial CT suggested a perirenal hematoma. Renal angiography was non-diagnostic, but exploration of adjacent vasculature revealed active bleeding from the adrenal artery, managed with embolization. Subsequent clinical deterioration with neurological deficits led to the discovery of multifocal septic emboli and mitral valve vegetation, confirming IE per Modified Duke Criteria despite negative blood cultures. This case highlights two key points: 1) the limitation of cross-sectional imaging in definitively distinguishing adrenal from renal hemorrhage, and 2) the critical importance of angiographic exploration beyond the initially suspected site when clinical and imaging findings are discordant. Unexplained hemorrhage with persistent coagulopathy should prompt investigation for occult IE, even in the absence of classic signs or positive cultures.