Presentation
Sudden flank pain and symptoms of shock (hypotension, tachycardia and diaphoresis). No previous medical conditions.
Patient Data
CT shows enlarged and dysmorphic kidneys (left: 21.6 x 12.5 x 15 cm; right: 18 x 9 x 15 cm) because of the presence of extensive and heterogeneous fat containing masses. The left sided mass contains some calcifications and density consistent with hematoma (15 x 10 x 10 cm) and hematoma also seen in the left pararenal space. No calculi seen in the path of the ureters. There is also fluid noticed in the abdominal cavity and a hepatic cyst.
Image of abdominopelvic CT in coronal plane, red arrow indicates a structure for one of the following questions.
Case Discussion
Wunderlich syndrome is a rare condition characterized by shock due to severe spontaneous renal hemorrhage into the subcapsular and perirenal space, its commonest cause is angiomyolipoma (AML). 1
Symptoms and the risk of bleeding increase with the size of the lesion (82-90% of angiomyolipoma >40 mm produce symptoms). 2,3
The demonstration of macroscopic fat (on all modalities) is key for the diagnosis of angiomyolipomas.4
The presence of hemorrhage or lesions that contain little fat may make it very difficult to distinguish AML from renal cell carcinoma.
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