Association Between Direct Oral Anticoagulants and Wunderlich Syndrome: A Case Report and a Comprehensive Analysis of the Literature and Evidence

Wunderlich syndrome (WS) is a rare condition, referring to spontaneous retroperitoneal haemorrhage, often linked to renal neoplasms and, infrequently, to anticoagulant use. We describe a case of a 79-year-old male with spontaneous renal bleeding whilst on edoxaban, in the absence of other risk factors. The patient presented with ambiguous symptoms, prompting an initial misdiagnosis of a urinary tract infection. Subsequent imaging demonstrated a right renal subcapsular haematoma with active bleeding, managed by selective arterial embolisation. The patient subsequently developed a persistent, infected collection, requiring multiple drainages and repeat embolisation due to concerns of ongoing haemorrhage. Multidisciplinary care led to a gradual resolution, and anticoagulation was withheld, with close follow-up. Our case highlights diagnostic challenges in anticoagulated patients with non-specific symptoms and underscores the importance of early imaging, careful anticoagulation management, and thorough embolisation. Given the limited data on WS risk across anticoagulants, further research and standardised management protocols are needed.