Wunderlich Syndrome in a Patient with ESKD Diagnosed with COVID-19: A Case Report

Introduction: Wunderlich syndrome is a rare clinical syndrome characterized by an acute onset of spontaneous renal hemorrhage into the subcapsular, perirenal, and/or pararenal spaces, without a history of antecedent trauma. Patients may present with a multitude of symptoms ranging from abdominal pain to serious manifestations such as hypovolemic shock. In this case report, we presented an end stage renal disease patient diagnosed with Covid 19 who developed Wunderlich syndrome. Case Description: This is a case of 68-year-old female, with known chronic kidney disease stage 5 on hemodialysis, presented with abdominal pain and hypotension. On the day of admission, patient was scheduled for over-the-wire IJ catheter exchange. Post-procedure, patient developed hypotension and abdominal pain localized to the right upper and lower quadrant. Despite fluid resuscitation, she remained hypotensive. Significant physical examination revealed bibasal crackles. On work up ,there was anemia (Hgb: 8.5g/dL, dropping to 6.6g/dL in 6 hours), and bilateral lower lung densities on chest X-ray. COVID RT PCR was positive. Other work up such as 12Lead ECG, 2D echo, Procalcitonin, Urinalysis, Liver Function Test were unremarkable. CT scan thoraco-abdominal aortogram was done which revealed right renal subcapsular acute hemorrhage. Since the patient was hemodynamically unstable, patient underwent renal angiogram with renal artery embolization. She was eventually weaned off inotropic support, anemia was corrected via blood transfusion and adequate antibiotic coverage was given for the pneumonia. Hemodialysis was continued. Following stabilization and completion of isolation, she was discharged. Follow-up imaging showed resolution of the renal subcapsular hemorrhage. Discussion: Wunderlich syndrome is a life threatening condition with high morbidity and can be fatal if not treated promptly and aggressively. End stage renal disease is a rare cause for Wunderlich syndrome. Patients with ESRD are predisposed to bleeding diathesis. Another rare but possible cause is the presence of COVID-19 infection in the patient. Studies have suggested that COVID-19 can cause a spontaneous hemorrhage and can increase incidence of bleeding. Both of these in combination can cause endothelial dysfunction which could lead to increased bleeding events.