Wunderlich's syndrome (spontaneous renal haemorrhage)

Wunderlich syndrome in a patient with pyelonephritis

An elderly female patient with left pyelonephritis developed worsening left flank pain, hypotension and a drop in haemoglobin (Hb) from 97 g/L to 67g/L on the third day of her admission. There was no recent trauma, history of coagulopathy or risk factors for renal malignancy or vascular disease.A contrasted CT scan of the kidneys revealed a 3.8 cm left renal subcapsular haematoma with no active contrast extravasation. Her atraumatic subcapsular haematoma fulfils two out of three clinical features of Lenk's triad (acute flank pain, hypovolaemic shock), suggestive of Wunderlich syndrome. Urine and blood cultures grew Klebsiella pneumoniae and she was managed conservatively with culture-directed antibiotics, fluids and blood products.Wunderlich syndrome is a rare complication of pyelonephritis and should be considered in patients with pyelonephritis who develop acute severe flank pain, Hb drop and haemodynamic instability. Appropriate medical and surgical therapies need to be instituted early to ensure good outcomes.

Spontaneous Subcapsular Renal Hematoma as Cause of Hypovolemic Shock in a Chronic Hemodialysis Patient

Subcapsular renal hematomas may appear spontaneously in patients in chronic hemodialysis, though other causes as neoplasms, vasculitis, and infections should be excluded. Patients may present with abdominal pain and hemorrhagic shock; hence, early diagnosis is vital. Nephrectomy or renal artery embolization are suitable treatment options.

Sporadic Renal Angiomyolipoma: Can We Adopt a Uniform Management Protocol?

Renal angiomyolipomas (AMLs), formerly known as PEComas (tumors showing perivascular epithelioid cell differentiation) are common benign renal masses composed of a varying ratio of fat, blood vessels, and smooth muscles. They are largely asymptomatic and diagnosed incidentally on imaging.

The adipose tissue content is the factor that gives AMLs their characteristic appearance on imaging and makes them easily identifiable. However, the fat-poor or fat-invisible varieties, which are difficult to differentiate radiologically from renal cell carcinomas (RCCs), present a diagnostic challenge. It is thus essential to establish the diagnosis and identify the atypical and hereditary cases as they require more intense surveillance and management due to their potential for malignant transformation.

Multiple management options are available, ranging from conservative approach to embolization and to the more radical option of nephrectomy. While the indications for intervention are relatively clear and aimed at a rather small cohort, the protocol for follow-up of the remainder of the cohort forming the majority of cases is not well established. The surveillance and discharge policies therefore vary between institutions and even between individual practitioners. We have reviewed the literature to establish an optimum management pathway focusing on the typical AMLs.

Spontaneous Rupture of Large Angiomyolipoma of the Kidney: A Rare Case

Angiomyolipoma is the most frequent neoplasm of the kidney. It may have a wide range of clinical manifestations, but it is usually detected incidentally on cross-sectional images. Rupture and hemorrhage of angiomyolipoma is an important concern for large lesions. We present the case of a 42-year-old female, with no history of urinary stones, who presented with a sudden-onset left flank pain for eight hours. Upon examination, she was tachycardic and hypotensive. Abdominal examination revealed a left-sided flank mass. Abdominal computed tomography (CT) scan with intravenous contrast demonstrated a heterogeneous mass lesion in the left kidney with mixed attenuation and had a macroscopic fat density that was surrounded by a large hematoma. Subsequently, transcatheter renal artery embolization was performed with no complications. The procedure was able to control the active bleeding. Then, a total nephrectomy was performed, and the hematoma was evacuated during laparotomy. Spontaneous nontraumatic renal hemorrhage is a very rare condition. Clinicians should keep a high index of suspicion for this condition when they encounter a patient with the clinical triad of flank pain, flank mass, and hypotension. The case demonstrated the role of endovascular embolization of angiomyolipoma to control life-threatening hemorrhage.

Collaborative, Innovative Quality Improvement Activity: Development of Queensland Ambulance Service Stickers: Drivers, Approaches, Implementation, and Outcomes

This article discusses the implementation of 3 targeted interventions aimed at reducing infection rates in patients due to prolonged in situ intravascular catheters (IVCs) during their admission to the hospital. These IVCs are inserted by paramedics with Queensland Ambulance Service (QAS) in prehospital settings. The 3 interventions involved were the application of "QAS-IVC" stickers by QAS paramedics to indicate QAS-inserted IVCs, the implementation of mandatory IVC documentation during patient handover, and clinician engagement to provide patient education on IVC infection signs. Audits undertaken in wards reflected that the interventions were apparent and beneficial; this is evident from the limited number of patients having in-dwelling QAS-IVC and increased awareness among medical staff and patients alike. We, however, did not have comparative data to objectively quantify the success of the interventions implemented.

Wunderlich Syndrome: An Unusual Cause of Abdominal Pain with Hypovolaemia

Wunderlich syndrome, or spontaneous retroperitoneal haemorrhage, is a rare but potentially fatal condition. I report a case of a middle-aged lady who presented with this rare condition where a bedside point-of-care ultrasound scan expedited the management of the patient. (Hong Kong j.emerg.med. 2013;20:385-388)

A diagnostic dilemma: lupus nephritis or renal polyarteritis nodosa?

Lupus nephritis and renal polyarteritis nodosa (PAN) are two distinct disorders that rarely overlap. Herein, we describe a patient who was initially diagnosed with lupus nephritis based on her clinical presentation, proteinuria, hematuria, positive anti-nuclear antibody, and a kidney biopsy. A month later, the patient presented with left flank pain and weakness. A CT scan of the abdomen and pelvis showed a perinephric hematoma and the renal arteriogram revealed numerous microaneurysms within the kidney consistent with renal PAN. This case elucidates the diagnostic and management dilemmas that confront physicians taking care of patients with overlapping features of lupus nephritis and renal PAN and also points to the possible role of lupus nephritis in pathogenesis of renal PAN.

Flank pain, nausea, vomiting and hypotension in a chronic hemodialysis patient with a spontaneous perirenal hemorrhage

Decreases in blood pressure develop in response to a wide range of clinical disorders. Various factors have been implicated in the development of hemodialysis-associated hypotension, including an impairment of the compensatory processes, an autonomic dysfunction or cardiac failure. The additional presence of concomitant acute abdomen may result in a diagnostically challenging situation. We herein report our experience with a chronic hemodialysis patient who developed severe hypotension with acute flank pain due to spontaneous bleeding around the kidney. Concerns regarding the management of the disease are also discussed.