A Case of Spontaneous Renal Haemorrhage (Wunderlich Syndrome) in an Anticoagulated Patient

Abstract

Spontaneous renal haemorrhage is a rare but severe condition known as Wunderlich syndrome (WS). The classic presentation includes sudden-onset flank pain, a palpable flank mass and hypovolaemic shock (Lenk's triad). WS can be due to neoplasms, vascular diseases, cystic rupture, coagulopathies and infections. A contrast-enhanced CT scan of the abdomen is mandatory for diagnosis. Surgery is reserved for haemodynamically unstable patients and those with neoplastic disease. We describe a case of WS in an anticoagulated patient with chronic atrial fibrillation, diabetes mellitus type 2 and hypertension, who developed acute renal failure and severe anaemia, that completely resolved with conservative treatment and discontinuation of anticoagulation therapy.

Learning points: Wunderlich syndrome refers to spontaneous renal or perinephric haemorrhage.Contrast-enhanced CT of the abdomen is the gold standard for diagnosis.Surgery should be reserved for haemodynamically unstable patients or those with neoplastic disease.

Keywords: Spontaneous renal haemorrhage; Wunderlich syndrome; anticoagulation; contrast-enhanced computed tomography; flank pain; renal haematoma.

Figure 1

Point-of-care ultrasound (PoCUS) showing an oedematous aspect with a coarse hypoechoic image in the superior pole of the right kidney (red arrow) in the absence of bilateral hydronephrosis and free abdominal fluid

Figure 2

Abdominal CT scan without contrast showing a voluminous (11.5×9.5×12.5 cm) and patchy right kidney (red arrows) suspicious for acute renal haemorrhage (panel A, axial view; panel B, coronal view)

Figure 3

Enhanced-contrast abdominal CT scan showing a right perirenal subcapsular haematoma (9×9.5 cm on the axial plane (A), and 12 cm of cranial-caudal extension (B)), without signs of active bleeding (red arrows)