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First Case of Wunderlich Syndrome under Apixaban – Case Report

1Centro Hospitalar Universitário Lisboa Norte - Imunohemoterapia, Lisbon, Portugal, 2Centro Hospitalar Lisboa Ocidental - Hosp. Santa Cruz - Cardiologia, Lisbon, Portugal, 3Centro Hospitalar Lisboa Ocidental - Hosp. São Francisco Xavier - Medicina Interna, Lisbon, Portugal, 4Hospital Espírito Santo - Évora - Medicina Interna, Évora, Portugal, 5Centro Hospitalar Lisboa Ocidental - Hosp. Egas Moniz - Unidade de Cuidados Intensivos Polivalente - ICU, Lisbon, Portugal, 6Centro Hospitalar Lisboa Ocidental - Hosp. Egas Moniz - Neurologia, Lisbon, Portugal

Abstract Number: PB0097

Meeting: ISTH 2021 Congress

Theme: Coagulation and Natural Anticoagulants » Critical Care and Perioperative

Background: Wunderlich syndrome (WS) is a rare and life-threatening syndrome presenting as spontaneous nontraumatic renal rupture with subcapsular and perinephric hemorrhage. Apixaban, a direct oral anticoagulant (DOAC) recommended in patients with atrial fibrillation (AF), has previously been associated with atraumatic solid organ rupture but, to date, no case of apixaban-related WS has been reported.

Aims: To discuss the first case of Wunderlich syndrome under Apixaban.

Methods: We report a case of a 79-year-old female with known atrial fibrillation under apixaban. She was admitted with sudden left flank pain and hypotension, blood tests revealed a hemoglobin of 9.2g/dL, platelets count of 188×109/L, creatinine of 2.05mg/dL (baseline of 0.85mg/dL). A computed tomography (CT) scan revealed an upper left renal rupture with extensive perirenal hemorrhage. Thus, a diagnosis of Wunderlich syndrome was made. She later developed obnubilation and hypotension. Blood analysis revealed hemoglobin of 6.4g/dL, mixed acidemia with a pH of 6.9 and lactate of 13.0mmol/L (reference value <2.0mmol/L). A diagnosis of hemorrhagic shock was assumed and the patient was transferred to the Intensive Care Unit for initiation of blood transfusion, vasopressor support and mechanical ventilation. Anticoagulation was suspended.

Results: Hemodynamic stability was achieved, however, at day seven of admission, she developed multiple ‘de novo’ cerebral embolic infarctions. She was deemed unsuitable for anticoagulation resumption given the recent major bleeding. At day 47 of admission, after excluding new bleeding events, anticoagulation with apixaban was resumed and she was discharged with ongoing improvement of neurological deficits and normal renal function.

Conclusions: We present the first-ever report of WS associated with DOAC.  A high-suspicion index must be maintained in patients presenting with flank pain and features of hemorrhagic shock, especially in those under anticoagulation. Management of patients with active bleeding while on DOAC is complex, particularly when simultaneous thromboembolic events occur.

To cite this abstract in AMA style:

Quaresma T, Maltês S, Carvalho Gouveia C, Canudo DJ, Rebelo M, Serrazina F, Deveza MM, Galvão M. First Case of Wunderlich Syndrome under Apixaban – Case Report [abstract]. Res Pract Thromb Haemost. 2021; 5 (Suppl 2). https://abstracts.isth.org/abstract/first-case-of-wunderlich-syndrome-under-apixaban-case-report/. Accessed October 1, 2023.

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