A tale of Wünderlich syndrome
A 63-year-old Caucasian female with no known history of trauma, anticoagulation or bleeding diathesis was presented to the emergency department with sudden-onset, sharp abdominal and right flank pain. The associated symptoms included near-syncope, diaphoresis, nausea and vomiting. Her personal history included renal calculus, hypertension and diabetes mellitus. Previous surgical history included back surgery for hemagioblastoma removal years ago, but she denied history of percutaneous nephrolithotomy. She claimed no known drug allergies and no recent changes in home medications.\nAlthough persistently hypotensive at her initial presentation, she later developed hemodynamic instability systolic blood pressure of 82 mmHg. She was stabilized with crystalloid fluid resuscitation without additional needs for blood products. A physical examination revealed a mildly obese, afebrile female with severe right upper quadrant, epigastric and costovertebral angle tenderness.\nThe patient's hemoglobin was 10.5 g/dl, creatinine 1.39 mg/dl, estimated glomerular filtration rate 38 ml/min/1.73 m2 and international normalized ratio of 1.1.\nA pre- and post-contrast CT scan of the abdomen and pelvis revealed a large right perinephric hematoma within the anterior aspect of the retroperitoneum (Fig. ). This hematoma distended the renal fascia, crossed the midline and displaced other peritoneal and retroperitoneal structures. Free fluid and a hyperdense focus of vascular contrast were present adjacent to the hematoma. The estimated size of the hematoma was 13 cm in the cephalocaudad, 12 cm in the transverse and 8.5 cm in the anteroposterior dimension. The vena cava, renal artery and renal vein were narrowed likely due to vasospasm, but the aorta was otherwise unremarkable.\nAn emergent renal angiogram revealed two right renal arteries with active contrast extravasation from the subsegmental branch of the superior right renal artery (Fig. A). This was successfully embolized (Fig. B). This case was clinically diagnosed as a spontaneous retroperitoneal hemorrhage with subcapsular hematoma, otherwise known as WS.\nA follow-up abdomen/pelvis CT/CTA demonstrated complete resolution of active extravasation and no pseudoaneurysm formation. The patient remained hemodynamically stable and was discharged home uneventfully. Her 3-month follow-up magnetic resonance imaging (MRI) did not reveal any remarkable findings.