Abstract: FR-PO017

Wunderlich Syndrome

Session Information

Category: Nephrology Education

  • 1302 Fellows and Residents Case Reports

Authors

  • Ahmed, Bilal, University of Oklahoma, Tulsa, Oklahoma, United States
  • Afzal, Muhammad, University of Oklahoma, Tulsa, Oklahoma, United States
  • Baradhi, Krishna M., University of Oklahoma, Tulsa, Oklahoma, United States
Background

Wunderlich syndrome is spontaneous, nontraumatic renal hematoma confined to perirenal and subcapsular space and is often due to underlying renal pathology. We herein present a rare case of wunderlich syndrome secondary to acute pyelonephritis.

Methods

55-year-old woman presented with fever, acute abdominal pain, nausea, vomiting and dizziness. Examination was pertinent for orthostatic hypotension and mild right flank tenderness. Initial labs showed acute kidney injury with creatinine of 4.8 mg/dl and Bun of 50 mg /dl along with anemia and leukocytosis. Urine sediment showed muddy-brown granular casts as well as pyuria with bacteriuria .She was diagnosed with acute pyelonephritis and acute tubular necrosis, which gradually improved with antibiotics and fluid resuscitation. However CT scan revealed a large right subcapsular perinephric hematoma concerning for renal cancer. A follow up contrast enhanced MRI, a week after her renal function improved showed much smaller and a more organized evolving right subcapsular renal hematoma making a diagnosis of wunderlich syndrome, which is indeed a rare complication of pyelonephritis. Patient was managed conservatively with eventual resolution of hematoma.

Conclusion

Spontaneous perinephric hematoma (SPH) also called wunderlich syndrome, first described by wunderlich in 1856, is characterized by lenk’s triad of abdominal pain, flank mass and hypovolemic shock. Most common etiologies are renal cell carcinoma, angiomyolipoma and vascular diseases. Amongst the rare causes include infectious and inflammatory renal diseases. Pyelonephritis complicating SPH is exceedingly rare and should be considered with intractable symptoms despite antibiotics or concurrent anemia without identified cause. Etiology and clinical severity dictates treatment, varying from close monitoring to nephrectomy. SPH requires high index of suspicion and careful investigation to rule out renal tumors and vascular disorders