Wunderlich syndrome: cross-sectional imaging review

Renal epithelioid angiomyolipoma: imaging characteristics in nine cases with radiologic-pathologic correlation and review of the literature

OBJECTIVE

The purpose of this study was to describe the imaging features of renal epithelioid angiomyolipoma (EAML), a rare subtype of angiomyolipoma, with clinical and pathologic correlation.

MATERIALS AND METHODS

This study was a retrospective review of nine cases from a single institution in which total resection and preoperative imaging were performed and the diagnosis of EAML was made. Imaging included CT (nine cases), MRI (five cases), and ultrasound (one case), and the images were reviewed in consensus by two radiologists. Patient demographics, disease associations, presentation, and outcomes were determined by chart review.

RESULTS

The patients were nine women and one man (mean age, 42 years). Two patients had tuberous sclerosis complex. The size of the nine EAMLs ranged from 1.4 to 22 cm (mean, 7.8 cm). Six lesions had minor components of fat identifiable at imaging. The contrast enhancement pattern was heterogeneous in eight lesions, five of which contained cysts, necrosis, and hematoma. Four presentations were acute hemorrhage, with ruptured EAML in three of the four. Five tumors extended into the renal sinus. Two tumors were locally invasive. One patient had metastatic disease at presentation with epithelioid tumor identified in a single lymph node. The follow-up periods ranged from 0 to 89 months, and there was one case of suspected but not yet proved recurrence.

CONCLUSION

Renal EAML can have a range of imaging appearances and can be indistinguishable from renal cell carcinoma and angiomyolipoma with minimal fat. EAML can be considered when a mass is found that has small foci of macroscopic fat without calcification or when acute hemorrhage of a renal mass occurs.

Perirenal hemorrhage secondary to interventional radiology operation against head and neck vessels: two cases report and review of the literature

Due to the hidden hemorrhage and a lack of specificity in its manifestations, perirenal hemorrhage as a complication of interventional radiology procedures is not always diagnosed in a timely manner; furthermore, the cause of hemorrhage is often misidentified or uncertain. In this report, two cases of elderly male patients who each had a perirenal hemorrhage on the same side after an interventional radiology operation against head and neck vessels by the same operator on the same day are described. This study demonstrated that the perirenal hemorrhages in both patients were related to the interventional radiology operations, providing a reminder that operating gently and always keeping the guide wire in sight during the insertion are critical for reducing the incidence rate of perirenal hemorrhage.

A tale of Wünderlich syndrome

Wunderlich syndrome is a rare entity characterized by acute onset of spontaneous, non-traumatic renal hemorrhage into the subcapsular and perirenal spaces. It can be fatal if not promptly recognized clinically and treated aggressively. We report a case of a 63-year-old Caucasian female who was presented to the emergency department with acute onset of sharp abdominal and right flank pain, and hypotension. An urgent abdominal and pelvic computed tomography scan with contrast demonstrated a large (13 × 12 × 8.5 cm) right perinephric hematoma of unknown etiology. The patient subsequently underwent renal angiogram that demonstrated active extravasation of the right superior renal artery. She underwent successful embolization procedure and responded well to fluid resuscitation. She remained hemodynamically stable and was discharged home without further events.

Wünderlich syndrome from lupus-associated vasculitis

Spontaneous perinephric hemorrhage is a clinically rare life-threatening condition, also known as Wünderlich syndrome. Presentations can be variable, but patients typically display symptoms and signs including flank or abdominal pain, abdominal mass, and hypovolemia. It is important to diagnose the syndrome early because untreated cases carry a high mortality risk, and prompt intervention with an endovascular procedure or surgery is life saving. Causes range from anatomical anomalies, including vascular diseases (vasculitides and aneurysms) and renal tumors, to functional coagulation defect (bleeding tendency). The most common causes of Wünderlich syndrome are renal angiomyolipoma and renal cell carcinoma, constituting 60%~70% of cases. Vascular causes of Wünderlich syndrome are infrequent, and the culprit most frequently is vasculitis resulting from polyarteritis nodosa. Other vasculitides presenting as Wünderlich syndrome are infrequent. We describe a 39-year-old woman with end-stage renal disease from lupus nephritis and spontaneous renal hemorrhage, ascribed to lupus-related vasculitis after serologic testing, computed tomography, and angiographic studies.