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A 45 year old woman presented to the accident and emergency department with a six hour history of central abdominal pain. The pain was of sudden onset, was constant in nature, radiated into both loins but not the back and was associated with vomiting. There were no urinary symptoms at initial presentation. On examination the patient appeared well with no systemic upset, temperature 36°C, pulse 60, and blood pressure 115/70. Abdominal examination revealed generalised tenderness but there were no signs of peritonism nor was there a definite mass to feel. Initial investigation including full blood count, electrolytes and amylase, chest and abdominal radiographs were normal. As the patient was unable to pass urine, a urethral catheter was passed draining about 400 ml of heavily blood stained urine.
Abdominal computed tomography was then performed revealing a large right retroperitoneal mass displacing the kidney anteriorly with a 10 cm mass in the lower pole. A smaller 5 cm mass was present in the lower pole of the left kidney and a small amount of free fluid was noted in the pelvis. A diagnosis of spontaneous haemorrhage from a renal cyst was made.
At this stage the patient’s circulatory state began to deteriorate, pulse 90, blood pressure 90/75, and a rapid transfusion of crystalloid and blood was given. The patient underwent renal angiography where a bleeding point was identified and successfully embolised. The patient remained stable thereafter and made a full recovery. Subsequent investigation did not reveal any underlying disease processes related to cyst formation.
Although renal cysts are commonly seen, spontaneous haemorrhage into a cyst causing a massive retroperitoneal haematoma and circulatory compromise is an extremely rare event. Spontaneous retroperitoneal haemorrhage from the kidney was first described by Bonnet in 1700, yet it was later in 1856 that Wunderlich gave his name to this rare condition.1 A standard search using Medline revealed that to date only 250 cases have been reported worldwide in the medical literature.1
Although in this case the presence of the shocked state and gross haematuria suggested urogenital abnormality, the diagnosis of haemorrhage into a renal cyst could only be made with radiological investigation, computed tomography being the preferred method.2 The treatment of choice is arterial embolisation in the first instance to control further haemorrhage rather than nephrectomy, with subsequent investigation aimed at excluding malignancy. Benign causes of Wunderlich syndrome may then be managed non-operatively.
Both Christopher Blakeley and Namasivayam Thiagalingham were involved in the initial management of the patient, the literature search and composition of the case report. Mr Kambiz Hashemi, A&E consultant, Mayday, has kindly agreed to be guarantor.
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