Bilateral adrenal infarction in pregnancy: a diagnostic challenge (a case report)

Bilateral adrenal infarction in pregnancy is a rare but potentially life-threatening condition that can lead to acute adrenal insufficiency and is often misdiagnosed due to nonspecific symptoms. We report a 25-year-old primigravida at 34 weeks presenting with abdominal and lumbar pain, fever, and vomiting, initially treated as acute pyelonephritis. Clinical deterioration with tachypnea and metabolic acidosis prompted further investigations. Computed tomography pulmonary angiography ruled out pulmonary embolism, while contrast-enhanced abdominal computed tomography revealed bilateral non-enhancing adrenal enlargement. Serum cortisol was inappropriately low (128.2 nmol/L), supporting acute adrenal insufficiency. Immediate intravenous hydrocortisone and therapeutic anticoagulation led to rapid improvement. The patient delivered vaginally at 38 weeks under epidural analgesia with stress-dose corticosteroids. This case highlights the importance of early imaging and prompt corticosteroid therapy in pregnant patients with unexplained persistent abdominal pain.