A CASE OF HEMMORRHAGIC SHOCK CAUSED BY WÜNDERLICH SYNDROME

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Wünderlich syndrome (WS) is a rare condition caused by acute renal hemorrhage and characterized flank pain, mass hypovolemic shock. We report complex case of WS in an elderly gentleman with left pain nausea. CASE PRESENTATION: An 81-year-old man diabetes mellitus type 2, end-stage disease on hemodialysis, chronic atrial fibrillation apixaban coronary artery history percutaneous intervention clopidogrel who presented to tertiary care center onset nausea for six hours. Upon arrival, the patient was found have blood pressure 78/54 mmHg ventricular paced rhythm at 70 bpm. His physical examination significant tenderness palpation over flank, as well palpable mass. hemoglobin presentation 12.1 gm/dL but repeat value resulted 6.6 gm/dL. Computed tomography (CT) abdomen pelvis revealed multiple cysts 25 x 11 cm hemorrhagic kidney concerning ruptured cyst extravasation extending retroperitoneum along psoas muscle. The emergently transfused packed red cells, four-factor prothrombin concentrate fresh frozen plasma reverse effect his anticoagulation antiplatelet therapy. A multidisciplinary decision reached that urgent nephrectomy would be associated prohibitively high perioperative risk, releasing hematoma into may result complex, uncontrollable hemorrhage. subsequently underwent arteriogram interventional radiology-guided selective embolization inferior pole artery. Repeat CT contrast showed stable renal, perinephric retroperitoneal hematoma. recovered from shock successfully weaned off vasopressor support. DISCUSSION: potentially life-threatening requires prompt recognition management. most common etiologies are malignant neoplasms (61%) followed angiomyolipomas (29.1%). Hemorrhagic cause WS, rupture space among rarest presentations. Emergent angioembolization effective. Follow-up often includes exploratory laparotomy or laparoscopy. However, if malignancy not clearly identified imaging, conservative management imaging reasonable alternative. CONCLUSIONS: Although rare, rapidly progressing mortality time-sensitive diagnosis emergent REFERENCE #1: 1. G Albi, L del Campo, D Tagarro, Wünderlich's Syndrome: Causes, Diagnosis Radiological Management, Clinical Radiology, Volume 57, Issue 9, 2002, Pages 840-845, ISSN 0009-9260, https://doi.org/10.1053/crad.2002.0981 #2: Zhang JQ, Fielding JR, Zou KH. Etiology spontaneous perirenal hemorrhage: meta-analysis. J Urol. 2002;167(4):1593-1596. doi:10.1097/00005392-200204000-00006 #3: Medda M, Picozzi SC, Bozzini G, Carmignani L. Wunderlich's Emerg Trauma Shock. 2009;2(3):203-205. doi:10.4103/0974-2700.55346 DISCLOSURES: No relevant relationships Ana de Diego Diaz, source=Web Response Jeany Villamizar, Ann Vu,