Management of Critical Wunderlich Syndrome: A Case Report and Review of Therapeutic Strategies

This case report presents a compelling instance of Wunderlich syndrome (WS), a rare and nontraumatic medical condition characterized by spontaneous renal hemorrhage into the subcapsular and perirenal spaces. WS poses unique diagnostic and management challenges due to its sudden and substantial hemorrhage presentation that is life-threatening, often accompanied by acute flank pain, hemodynamic instability, and the presence of a flank mass. While the exact pathogenesis remains debated, WS can arise from various renal pathologies, including neoplastic and nonneoplastic conditions. In this case, a 65-year-old male with a complex medical history, including polycystic kidney disease, presented to the emergency room with massive hematuria leading to an abrupt severe drop in hemoglobin levels and hemodynamic instability. Despite aggressive management, including transfusions, the patient ultimately underwent an urgent open left radical nephrectomy due to the severity of the condition and distorted anatomy. Additionally, the report draws attention to the potential use of tranexamic acid in WS cases, stressing the importance of balancing its benefits against associated risks. This case highlights the critical importance of recognizing and promptly addressing WS, highlighting the diverse etiology of this condition, the role of tranexamic acid in controlling bleeding, and the lifesaving role of nephrectomy in cases of significant bleeding and hemodynamic instability.