Hypovolemic shock due to Wunderlich syndrome (spontaneous renal haemorrhage): a case report and literature review.

Andrea Vercelli; Laura Pagani; Konstantinos  Christodoulakis; Gennaro Marcello; Marcello Petrini; Emanuele Michieletti; Chiara Celaschi; Gianfranco Cervellin; Erika Poggiali

doi:10.23750/abm.v94i3.14087

Hypovolemic shock due to Wunderlich syndrome (spontaneous renal haemorrhage): a case report and literature review.

Authors

Andrea Vercelli Emergency Department, “Guglielmo da Saliceto” Hospital, Piacenza, Italy Via Giuseppe Taverna 49, Piacenza, Italy.
Laura Pagani Emergency Department, “Guglielmo da Saliceto” Hospital, Piacenza, Italy Via Giuseppe Taverna 49, Piacenza, Italy.
Konstantinos Christodoulakis Urology Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
Gennaro Marcello Urology Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
Marcello Petrini Radiology Unit, Department of Radiological Functions, Guglielmo da Saliceto Hospital, Piacenza, Italy
Emanuele Michieletti Radiology Unit, Department of Radiological Functions, Guglielmo da Saliceto Hospital, Piacenza, Italy
Chiara Celaschi Anatomical Pathology Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
Gianfranco Cervellin Academy of Emergency Medicine and Care, Pavia, Italy
Erika Poggiali .

DOI: https://doi.org/10.23750/abm.v94i3.14087

Keywords:

Wunderlich syndrome, Lenk’s triad, flank pain, renal haemorrhage, haemorrhagic shock, hypovolemic shock, acute renal injury.

Abstract

Wunderlich syndrome (WS) or spontaneous renal haemorrhage is a rare and life-threatening condition often leading to haemorrhagic shock. WS is characterized by an acute onset of non-traumatic subcapsular and perirenal haematoma formation due to several causes, including neoplasms, cystic rupture, vasculitis, coagulopathies, and infections. The classical presentation includes acute flank or abdominal pain, a palpable flank mass and hypovolemic shock (Lenk’s triad). Nausea, vomiting, fever, and haematuria can also be present. Computed tomography angiography is mandatory to localize the source of haemorrhage. Super-selective embolization can be performed to stop bleeding, while surgery is reserved to haemodynamic unstable patients and neoplastic cases. We describe a case of WS in a 79-year-old male patient, who rapidly developed hypovolemic shock requiring urgent nephrectomy.

References

Katabathina VS, Katre R, Prasad SR, Surabhi VR, Shanbhogue AK, Sunnapwar A. Wunderlich syndrome: cross-sectional imaging review. J Comput Assist Tomogr 2011;35(4):425-433. doi: 10.1097/RCT.0b013e3182203c5e.

Medda M, Picozzi SC, Bozzini G, Carmignani L. Wunderlich's syndrome and hemorrhagic shock. J Emerg Trauma Shock 2009;2(3):203-205. doi: 10.4103/0974-2700.55346.

Lenk R. Uber Massenblutungen in das Nirenlager. Dtsch Zeits Chir. 1909;102:222.

Parmar N, Langdon J, Kaliannan K, Mathur M, Guo Y, Mahalingam S. Wunderlich Syndrome: Wonder What It Is. Curr Probl Diagn Radiol 2022;51(2):270-281. doi: 10.1067/j.cpradiol.2020.12.002.

Zhang JQ, Fielding JR, Zou KH. Etiology of spontaneous perirenal hemorrhage: a meta-analysis. J Urol 2002;167(4):1593-1596. doi:10.1097/00005392-200204000-00006.

Albi G, del Campo L, Tagarro D. Wunderlich's syndrome: causes, diagnosis and radiological management. Clin Radiol 2002;57(9):840-845.

Chung R, Chawla A, Peh WC. Clinics in diagnostic imaging (178). Wunderlich syndrome and pseudoaneurysm. Singapore Med J 2017;58(6):289-293. doi:10.11622/smedj.2017049.

Ramirez-Limon DA, Gonzaga-Carlos N, Angulo-Lozano JC, Miranda-Symes O, Virgen-Gutierrez F. Wunderlich Syndrome Associated With Angiomyolipomas. Cureus 2022;14(4):e23861. doi:10.7759/cureus.23861.

Kim JW, Kim JY, Ahn ST, et al. Spontaneous perirenal hemorrhage (Wunderlich syndrome): An analysis of 28 cases. Am J Emerg Med 2019;37(1):45-47. doi:10.1016/j.ajem.2018.04.045.

Mariolis-Sapsakos T, Nannou E, Angelis S, Filippou D. Wunderlich Syndrome: Spontaneous Cystic Rupture on Account of Acquired Kidney Atrophy. Cureus 2022;14(10):e30386. doi:10.7759/cureus.30386.

García-Chairez LR, Montelongo-Rodríguez FA, Moreno-Arquieta IA, Ayala MM, Gutierrez-González A. Unusual Presentation of Wunderlich Syndrome. Ochsner J 2022;22(3):273-276. doi:10.31486/toj.21.0120.

Prawira M, Pramod SV, Wijayanti Z. Wunderlich syndrome in a COVID-19 patient with poor outcome. Urol Case Rep 2022;45:102267. doi:10.1016/j.eucr.2022.102267.

Presicce F, Martini M, Minisola F, Falavolti C, Filianoti A. Wunderlich syndrome, an unexpected urological complication in a patient with coronavirus disease 2019 (COVID-19): A case report. Curr Urol 2022;16(2):74-76. doi:10.1097/CU9.0000000000000100.

Senthilkumaran S, Miller SW, Williams HF, et al. Development of Wunderlich syndrome following a Russell's viper bite. Toxicon 2022;215:11-16. doi:10.1016/j.toxicon.2022.06.004.

Simkins A, Maiti A, Cherian SV. Wunderlich Syndrome. Am J Med 2017;130(5):e217-e218. doi:10.1016/j.amjmed.2016.11.031.

Dhanapal V, Ramachandran R, Radhan P, Vivekanandan B, Jeevanandham B, Jacob P. The many facets of Wunderlich syndrome: A multidetector computed tomography based review. Int J Contemp Med 2019;41:A88–A93.

Kaleta F, Sankhyan P, Sahebazamani M. Wunderlich syndrome: a case of hypovolemic hemorrhagic shock. Chest 2020;158(4 Supplement):A1024. doi: 10.1016/j.chest.2020.08.951.

Baishya RK, Dhawan DR, Sabnis RB, Desai MR. Spontaneous subcapsular renal hematoma: A case report and review of literature. Urol Ann 2011;3(1):44-46. 10.4103/0974-7796.75852.

Mabjeesh NJ, Matzkin H. Spontaneous subcapsular renal hematoma secondary to anticoagulant therapy. J Urol 2001;165(4):1201.

Ferrando F, Budía A, Mira Y, Vayá A, Aznar J. Spontaneous renal subcapsular hematoma in an anticoagulated patient. Clin Appl Thromb Hemost 2006;12(1):89-92.

Giovini M, Poggiali E, Zocchi P, Bianchi E, Antonucci E, Barbera M. A Case of Spontaneous Renal Haemorrhage (Wunderlich Syndrome) in an Anticoagulated Patient. Eur J Case Rep Intern Med 2022;9(4):003269. Published 2022 Apr 1. doi:10.12890/2022_003269.

Maltês S, Carvalho Gouveia C, Serrazina F, Rebelo M. Life-Threatening Wunderlich Syndrome Associated with Apixaban and the Complexity of Anticoagulation Management in Bleeding Patients: A Case Report [published online ahead of print, 2022 Jul 8]. Acta Med Port 2022;10.20344/amp.16941. doi:10.20344/amp.16941.

Chan YC, Morales JP, Reidy JF, Taylor PR. Management of spontaneous and iatrogenic retroperitoneal haemorrhage: conservative management, endovascular intervention or open surgery? Int J Clin Pract 2008;62(10):1604-13.

Paparella MT, Eusebi L, Gangai I, Bartelli F, Guglielmi G. Wunderlich syndrome: a rare case in a young woman. Acta Biomed 2021;92(S1):e2021113. Published 2021 Oct 6. doi:10.23750/abm.v92iS1.11185.

Jain V, Ganpule A, Vyas J, et al. Management of non-neoplastic renal hemorrhage by transarterial embolization. Urology 2009;74(3):522-526. doi:10.1016/j.urology.2008.11.062.

Ahn T, Roberts MJ, Navaratnam A, Chung E, Wood S. Changing etiology and management patterns for spontaneous renal hemorrhage: a systematic review of contemporary series. Int Urol Nephrol 2017;49(11):1897-1905.