Renal angiomyolipoma with hemorrhage - Wunderlich syndrome

Case contributed by Mohamed Saber
Diagnosis certain

Presentation

Acute severe flank pain with fainting and confusion. on examination, the patient showed signs of shock with hypotension and tachycardia.

Patient Data

Age: 45 years
Gender: Female

Ultrasound study shows a right renal fossa sizable echogenic mass lesion with a peripheral component of turbid septated fluid-like echogenicity.

Incidental gallbladder stone.

CT study shows right renal/ perirenal space sizable fat-containing exophytic mass lesion of complex density measures 10x10x15 cm, shows a large fatty component, with a peripheral soft tissue-like density seen predominantly medially mostly representing clotted blood. An internal localized area of fat-blood level and perinephric fat stranding is also noted. The right kidney appears displaced and compressed with a shaggy irregular outline more prominent at its upper and mid zones.

Right hepatic lobe segment VII subcapsular small focal lesion measures 25 mm mostly a hemangioma.

Gallbladder stone and right mild pleural effusion.

Case Discussion

Wunderlich syndrome is a rare condition in which spontaneous non-traumatic renal hemorrhage occurs into the subcapsular and perirenal spaces. It is clinically characterized by Lenk's triad; acute flank pain, flank mass, and hypovolemic shock.

It may be secondary to neoplastic or non-neoplastic causes. Among benign neoplasms, angiomyolipoma is the commonest, while among malignancies, renal cell carcinoma is the commonest.

After resuscitation, this patient was transferred for emergency embolization.

Ultrasound contribution by Dr. Somia Elbadawy

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