Life-Threatening Wunderlich Syndrome Associated with Apixaban and the Complexity of Anticoagulation Management in Bleeding Patients: A Case Report

Abstract

Wunderlich syndrome is a rare and possibly life-threatening haemorrhagic syndrome presenting as spontaneous nontraumatic renal rupture with subcapsular and perinephric haemorrhage. Apixaban, a direct oral anticoagulant recommended in patients with atrial fibrillation, has previously been associated with atraumatic solid organ rupture but, to date, no case of apixaban-related Wunderlich syndrome has been reported. We report a rare case of Wunderlich syndrome associated with apixaban while addressing the difficulties face by clinicians when managing anticoagulation in bleeding patients.

Bilateral renal hemorrhage in an anticoagulated patient: A rare case of Wunderlich syndrome

“…Imaging plays a crucial role in a suspected case of WS as it confirms the diagnosis by detecting the renal hemorrhage; gives information on the extent and location of the bleeding in the subcapsular, perirenal and/or pararenal space; and provides a possible underlying cause for the bleeding, since it might show renal vascular structure, origins of tumors and pathological change in adjacent tissues [ 2 , 6 ]. CT has the highest sensitivity in identifying perirenal hemorrhage among the imaging modalities.…”

“…After contrast medium administration, on the venous phase, the hemorrhage is hypodense to iso-dense in relation to the enhanced renal parenchyma [7] . Post-contrast scans are critical to assess the presence of an active extravasation of contrast material indicative of ongoing hemorrhage requiring urgent consultation [ 2 , 6 ].…”

“…The patient's anticoagulant therapy was identified as the cause of the bleeding. Currently, to our knowledge, similar cases of WS associated with anticoagulant therapy have rarely been described [ 3 , 6 ]. The management of WS can be difficult, especially in anticoagulated patients since there are no well-defined clinical guidelines for management.…”