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• W3204971566 abstract "TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: We present a rare case of perinephric hemorrhage causing hypertension & clinically significant bleeding after initiation of antiplatelet therapy. CASE PRESENTATION: A 44-year-old male with history of medulloblastoma, status post resection & irradiation, presented with slurred speech & ataxia. Cerebral angiogram showed bilateral vertebral artery & proximal basilar artery occlusion, for which he underwent emergent thrombectomy & stenting. He was then started on aspirin & clopidogrel. A day after, he complained of new-onset severe left flank pain with fever, tachycardia, & hypertension. Nicardipine drip was given to control his blood pressure. Hemoglobin dropped from 15.7 to 11.4 g/dL. Serum creatinine increased to 1.7 from a baseline of 1.2 mg/dL. Urinalysis showed RBC of 10-20/high-power field. Computed tomography (CT) of the abdomen showed a large left renal subcapsular hematoma measuring 3.0 x 5.7 x 6.3 cm in size, with delayed nephrograms from recent endovascular stent placement, indicative of delayed renal function, but no evidence of contrast extravasation or subcapsular rupture. Given the patient's recent stenting, antiplatelet therapy was continued. Urology & interventional radiology were consulted. The hematoma was managed conservatively with serial hemoglobin checks. Interval CT of the abdomen showed a stable hematoma. Patient later had resolution of hypertension & acute kidney injury, & was discharged home with close follow-up. DISCUSSION: Wunderlich syndrome is a rare phenomenon characterized by sudden onset of spontaneous renal or perinephric hemorrhage. Due to extrinsic compression of the renal parenchyma, renin-angiotensin-aldosterone system is activated & can result in systemic hypertension in a phenomenon known as Page kidney. Up to 60% of cases of perinephric hemorrhage are caused by a neoplasm, & a smaller portion is attributed to vasculitis, renal artery aneurysm, arteriovenous malformation, renal vein thrombosis, nephritis, cystic renal disease, & coagulopathy. In our patient's case, there was no appreciable mass on CT. It was thought to be secondary to initiation of antiplatelets. Contrast-enhanced CT of the abdomen has 100% sensitivity & is the gold-standard in identifying perinephric hemorrhage & can aid in renal embolization as treatment. Management includes selective arterial embolization & surgery. Embolization is minimally invasive; however, surgical intervention is used when tumor resection is needed & can prevent recurrent tumor bleeding. CONCLUSIONS: Wunderlich syndrome can be a life-threatening emergency. A high index of suspicion is warranted in a patient who has acute onset of flank pain, tachycardia, fever, & new-onset hypertension, especially after initiation of antiplatelet agents. REFERENCE #1: Dopson SJ, et al. Page kidney as a rare cause of hypertension: case report & review of the literature. Am J Kidney Dis. 2009 Aug;54(2):334-9. doi: 10.1053/j.ajkd.2008.11.014. Epub 2009 Jan 23. PMID: 19167799 REFERENCE #2: Lin YY, et al. Diagnosis of Wunderlich syndrome in a patient with flank pain. Hong Kong Med J. 2019 Oct;25(5):406.e1-2. doi: 10.12809/hkmj187718. PMID: 31761752 REFERENCE #3: Grassia M, Romano A, Esposito G, et al. A rare case of Wunderlich syndrome five days after left hemicolectomy for colorectal cancer. Int J Surg Case Rep. 2015;16:33-36. doi:10.1016/j.ijscr.2015.09.007 DISCLOSURES: No relevant relationships by Luqman Baloch, source=Web Response No relevant relationships by Janine Beatrice Borja, source=Web Response No relevant relationships by Shadi Obeidat, source=Web Response No relevant relationships by Lintu Ramachandran, source=Web Response" @default.
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• W3204971566 date "2021-10-01" @default.
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• W3204971566 title "PAGE KIDNEY IN WUNDERLICH SYNDROME AFTER DUAL ANTIPLATELET THERAPY" @default.
• W3204971566 doi "https://doi.org/10.1016/j.chest.2021.07.804" @default.
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