Subcapsular hematoma as a complication of acute pyelonephritis: a case report

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 haematoma in a diabetic patient with acute pyelonephritis

Spontaneous renal subcapsular haematoma is not a common clinical condition. It is mainly caused by renal tumours, vascular diseases, trauma, anticoagulation, and urological interventions. Patients present with sudden onset abdominal pain mainly in the flank region, haematuria, and abdominal tenderness. We report a case of 42-year-old diabetic patient who presented with a history of fever and left flank pain with clinical signs of pyelonephritis, on whom abdominal ultrasound and computed tomography demonstrated a subcapsular renal haematoma which was confirmed by percutaneous aspiration. Management with antibiotics and percutaneous nephrostomy proved successful.

Bilateral acute pyelonephritis with left renal artery aneurysm as a cause of bilateral spontaneous subcapsular haematoma: lessons learnt

Forniceal ruptures after acute pyelonephritis are relatively common. Bilateral spontaneous subcapsular haematoma (SSCH) is an uncommon sequela to pyelonephritis. We report a case of SSCH where the underlying cause of haematoma was a vascular anomaly. A 38-year-old woman with diabetes presented with fever, flank pain and shock following cystoscopy and Double J stenting done elsewhere. CT abdomen showed left subcapsular renal haematoma, managed by pigtail insertion. Postoperative CT showed right renal subcapsular haematoma and left moderate renal subcapsular haematoma. Renal angiogram showed pseudo-aneurysm on the left middle polar artery for which selective embolisation was performed. Physicians and urologists who come across SSCH for which no definite aetiology could be identified should keep in mind the possibility of an underlying vascular anomaly that could precipitate such a condition. The purpose of this report is to highlight the importance of remembering vascular causes in such unexplained cases of SSCH.

Recurrent infectious subcapsular renal hematoma accompanied by microaneurysm

An 80-year-old woman was admitted to the hospital complaining of loss of appetite. 10 days earlier, her oral intake gradually decreased with no other specific symptoms, such as abdominal pain, nausea, vomiting, headache, or low back pain. Abdominal computed tomography (CT) scan revealed a left subcapsular renal hematoma. We suspected infective subcapsular renal hematoma, so percutaneous needle aspiration and drainage were performed. Intravenous sulbactam-ampicillin was started immediately. On day 9 after admission, repeat CT scan revealed the subcapsular hematoma had reduced in size. The drain was removed, and intravenous antibiotics were discontinued. Follow-up CT scan on day 21 revealed increased subcapsular renal hematoma size. The patient also had high fever. Suspecting recurrence of infective subcapsular renal hematoma, we repeated the drainage of the hematoma and restarted intravenous antibiotics. Renal arteriography showed a renal artery microaneurysm and her condition improved with renal artery embolization. Renal arteriography was useful for detecting renal artery microaneurysm in infective subcapsular renal hematoma that did not resolve after antibiotic treatment and drainage.

Spontaneous Subcapsular Renal Hematoma as a Complication of Acute Pyelonephritis: A Case Report

Spontaneous subcapsular renal hematoma (SSRH) emerged as a complication of acute pyelonephritis (APN) is an extremely rare condition. We showed a patient aged 63 years hospitalized due to languor, febrility, abdominal pain accompanied by nausea and vomiting. Ultrasound (US) examination of the abdomen and multidetector computed tomography (MDCT) showed the presence of subcapsular hematoma of the left kidney with calculus in the initial part of the left ureter. Laboratory tests registered a positive inflammation syndrome, anemia and an increase in nitrogen compounds. Based on laboratory results, clinical presentation and imaging techniques it has been found that it is APN with spontaneous subcapsular hematoma. After application of non-surgical treatment which included antibiotic therapy with percutaneous drainage of hematoma, a good clinical response with regression of subjective symptoms and hematoma was obtained. On repeated US and MDCT after 18 months no pathological changes in the kidneys were registered. Spontaneous subcapsular hematoma extremely rare occurs as a result of APN associated with calculosis. The use of non-surgical treatment, which includes appropriate antibiotic therapy with percutaneous drainage of hematoma would represent a method of first choice.

Emphysematous pyelonephritis initially presenting as a spontaneous subcapsular hematoma in a diabetic patient

Emphysematous pyelonephritis (EPN) is a life-threatening infection characterized by the formation of gas. Complications of EPN include septic shock, acute renal failure, and disseminated intravascular coagulation. Spontaneous subcapsular hematoma (SCH) has also been reported as a rare complication of EPN, although there have been no reports to date of this occurring prior to the presentation of EPN. We report a case of EPN that initially presented as spontaneous SCH. The patient was admitted for left flank pain, and initial computed tomography revealed SCH without any air shadows. Laboratory findings and clinical symptoms suggested the presence of urinary tract infection and the patient was started on antibiotics. Fever developed 24 hours after admission. On follow-up computed tomography 7 days later, EPN was newly observed, and a percutaneous drain was inserted. Blood, urine, and drainage fluid cultures all revealed growth of extended-spectrum β-lactamase-negative Escherichia coli.

Wunderlich syndrome: cross-sectional imaging review

Wunderlich syndrome (WS) is a rare condition characterized by acute onset of spontaneous, nontraumatic renal hemorrhage into the subcapsular and perirenal spaces. Wunderlich syndrome is classically characterized by the Lenk's triad: acute flank pain, flank mass, and hypovolemic shock. However, the clinical manifestations can be varied and nonspecific. A wide spectrum of neoplastic and nonneoplastic renal pathologies may result in WS. Renal neoplasms are the most common cause for WS, with angiomyolipoma being the most common benign neoplasm, whereas renal cell carcinoma is the most common malignant neoplasm. Other causative conditions of WS include vascular causes (vasculitis [polyarteritis nodosa being the most common cause], renal artery aneurysms, arteriovenous malformations and fistulas, and venous thrombosis), cystic renal diseases, renal infections, calculus disease, nephritis, and coagulation disorders. Cross-sectional imaging findings help in the detection of the subcapsular and/or perinephric hemorrhage and may identify underlying etiology. Renal angiography not only helps in diagnosis of the underlying cause in select cases but also allows control of active bleeding, which can avoid unnecessary emergent radical surgery.

Subcapsular renal hematoma complicating acute pyelonephritis

Subcapsular renal hematoma (SRH) is an extremely rare complication of acute pyelonephritis (APN). We report a case of SRH complicating APN with a ureteral stone, together with a review of the literature.