#3351 A case report on Wunderlich syndrome in a 32-year-old male: diagnostic and clinical challenges

Abstract Background and Aims In patients presenting with flank pain, when the most common causes like urinary tract infection, nephrolithiasis, gallbladder disease among many others do not coincide with the clinical picture, spontaneous renal hemorrhage or Wunderlich syndrome must be sought. This is a life-threatening condition, much rarer than hemorrhage secondary to drug-induced and traumatic conditions. Given the rarity and the severity of this condition, it is essential to identify this at the shortest time possible. Wunderlich syndrome is a severe and rare condition manifested by an acute onset of spontaneous renal hemorrhage into the pararenal, perirenal or subcapsular spaces in the absence of inciting trauma. Classic symptoms of flank mass, flank pain and hypovolemic shock makes up for the Lenk triad seen in less than a quarter of patients. Given acute flank pain as the universal presenting symptom, the most appropriate to be performed in the emergency department is an abdominal CT scan. Most cases are attributed to renal neoplasms (60–65%), renal vascular diseases (20–30%) and renal infections among many others. Wunderlich syndrome has been described more than a century ago with only 165 cases reported worldwide from 1985 to 1999, reduced to 102 cases between 2000 and 2016, and eventually to 41 cases between 2016 and 2022, reflecting its rarity. In the Philippines, only one (1) has been documented. Although rare, a high index of suspicion for spontaneous renal hemorrhage is vital as this presents with insignificant symptomatology but should be managed critically. Once established, conservative measures must be done to stabilize the patient. Identification of cause should be sought to decide whether to pursue surgical intervention. At times, renal arterial embolization can be an option if urgent nephrectomy is not required. In this study, a case of Wunderlich syndrome in a young adult presenting with sudden right flank pain, declining blood pressure with findings of right renal hematoma and active bleeding of the right inferior polar artery is described. After prompt management, clinicians successfully prevented hemodynamic instability resulting to favourable outcome. This report highlights the diagnosis, optimal management and further elaborate the disease entity. Method Case Report Results After renal angiogram and embolization, angiogram showed occlusion of the branches of the right inferior polar artery. The patient's systolic BP was stable at 120–130mmHg. His hemoglobin level was steady at 12.3 g/dL with normal renal function (eGFR of 91 mL/min/1.73 m2) and complete resolution of hematuria. One week after discharge, CBC showed no further decline in hemoglobin and abdominal ultrasound showed right perinephric hematoma measuring 11.3 cm x 9.5 cm x 4.1 cm with an estimated volume of 231.51 mL. One month after discharge, repeat ultrasound revealed a significant decrease in size of the previously noted hematoma, now measuring 6.2 x 2.9 x 6.6cm with an estimated volume of 64 mL. Overall, well-being has improved. Conclusion Among the plethora of causes responsible for left flank pain, Wunderlich Syndrome, needs due consideration while ruling out the common differentials. The timing and choice of diagnostic imaging is important, as it helps guide treatment by identifying the cause of the disease. However, if the patient has life-threatening symptoms, imaging may be delayed until the patient's condition has stabilized. Conservative management with follow-up imaging is a good approach to avoid unnecessary surgery. By delving into this rare occurrence and its characteristics and outcomes, the goal is to shed insights on the complexities of a dreaded complication, a relatively benign condition that can rise.