WONDERING ABOUT WUNDERLICH SYNDROME: A RARE CASE OF SPONTANEOUS RENAL HEMORRHAGE L Tauhid BS, A Loghmani DO, K Oakden MD Department of Internal Medicine, Louisiana State University Health, New Orleans, LA INTRODUCTION: Wunderlich Syndrome (WS) is the rare syndrome of spontaneous renal subcapsular and retroperitoneal hemorrhage in the absence of known trauma. Traumatic and iatrogenic causes must be excluded prior to making the diagnosis. Renal mass is the leading cause of WS. Early recognition, prompt volume resuscitation and urgent surgical treatment are the mainstays of treatment. CASE: A 77-year-old man with hypertension, diabetes mellitus, atrial fibrillation on Apixaban, chronic lymphocytic leukemia (CLL) in remission and end stage renal disease (ESRD) on hemodialysis presented to an outside facility for generalized weakness, profound hypotension, and flank pain. The patient complained of flank pain for 3 days. He was found to have microcytic anemia requiring blood products, leukocytosis and tachycardia. Computed Tomography (CT) of the abdomen without contrast revealed a renal mass with hypothesized etiology of abscess given his leukocytosis. The patient was given intravenous antibiotics, transfused blood, and transferred to our hospital for Urologic evaluation. Repeat CT of the abdomen with contrast showed a large subcapsular hematoma around the left kidney with hemorrhage. The patient’s shock was due to hemorrhage and acute anemia resolved with transfusion and the hemorrhage resolved spontaneously. The leukocytosis was ultimately found to be due to a worsening CLL. DISCUSSION: Classic presentation of WS includes Lenk’s triad: acute onset flank pain, flank mass, and hemorrhagic shock. 25% of cases present with the triad, while 60-90% present only with flank pain. Our patient presented with flank pain, hypotension, and visible mass on imaging. Prominent underlying etiologies include renal neoplasms (60%), most commonly renal cell carcinoma (RCC), and renal vascular disease (20%) such as polyarteritis nodosa and renal artery disease. Other causes include cystic renal disease, infection, and anticoagulation induced. Possible etiologies in our patient include neoplasm, renal cysts from ESRD, and anticoagulation induced. These presentations are often thought to be due to renal colic or pyelonephritis, but physicians should consider WS in patients with flank pain, hemodynamic instability, and low hemoglobin which should prompt emergent imaging, notably CT with contrast to determine the underlying cause.
36
Made with FlippingBook Digital Publishing Software