Spontaneous Renal Hemorrhage in an Anticoagulated Patient With Prior Large-Vessel Vasculitis: A Wonder of Its Own

Wunderlich syndrome (WS) is a spontaneous renal or perinephric hemorrhage occurring in the absence of trauma.Renal neoplasms are the most common cause, although vascular, infectious, cystic, and coagulopathic etiologies also occur.When active extravasation is detected on imaging, angiography with embolization is the preferred approach.We report a case of an 81-year-old woman with atrial fibrillation on apixaban and large-vessel vasculitis complicated by aortitis and a prior intramural aortic hematoma, who presented with four days of weakness, nausea, diarrhea, and right-sided abdominal pain, and was hypotensive at 71/56 mmHg.Contrast-enhanced computed tomography (CT) demonstrated a 12 × 12 cm right perinephric hematoma with active extravasation from a serpiginous vessel at the lower renal pole.Interventional radiology recommended medical management rather than embolization, citing the procedural risk associated with her aortitis.Treatment consisted of discontinuation of anticoagulation, reversal with prothrombin complex concentrate and vitamin K, transfusion of three units of packed red blood cells, crystalloid resuscitation, and vasopressor support.The course was complicated by oliguric acute kidney injury, with creatinine rising from 1.30 to 3.72 mg/dL, and by Escherichia coli bacteremia of urinary source.Serologic evaluation demonstrated a positive perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA) result, with negative myeloperoxidase (MPO) and proteinase 3 (PR3) antibodies, and pulse methylprednisolone was administered.Urine output was reestablished with intravenous furosemide, vasopressors were discontinued by hospital day 4, and creatinine returned to 1.38 mg/dL before discharge on hospital day 7.This case demonstrates that conservative management can achieve hemodynamic and renal recovery in WS with active extravasation when vascular comorbidity precludes embolization.