Wunderlich Syndrome as First Manifestation of Infective Endocarditis
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Wunderlich Syndrome as First Manifestation of Infective Endocarditis Jose ´ Miguel Alapont, 1 Jose ´ Luı ´s Pontones, 1 Alvaro Go ´mez-Ferrer, 1 Salvador Rivas 2 and Juan Fernando Jime ´nez-Cruz 1 From the Departments of 1 Urology and 2 Pathology, La Fe University Hospital, Valencia, Spain (Submitted May 17, 2002. Accepted for publication May 31, 2002) Scand J Urol Nephrol 37: 90–92, 2003 Infective endocarditis (IE) presents with several signs and symptoms that are mainly heart-related and the result of bacteremia. We describe the case of a woman with severe renal hemorrhage due to a septic embolic cortical infarction, who was also receiving anticoagulation therapy because of cardiopathy, whose retroperitoneal hematoma was the first manifestation of IE. Key words: infective endocarditis, nephrectomy, Wunderlich syndrome. Jose ´ Miguel Alapont, Service of Urology, La Fe University Hospital, Avda. Campanar 21, ES-46009 Valencia, Spain. Fax: 34 96 3862760. E-mail: [email protected] The predominant manifestations of infective endocar- ditis (IE) are heart-related; however, in 50% of cases (1) the presence of bacteremia reveals signs and symptoms from any organ affected by septic emboli, such as the spleen, lung, kidney, liver, central nervous system (CNS), etc. Spontaneous renal hemorrhage is a life-threatening and diagnostically challenging condi- tion. It is rarely truly spontaneous, being mainly caused by tumors, vascular abnormalities and inflammatory disorders. Only in rare cases is infarction the cause of perinephric hematoma (2). We present the case of a patient with secondary severe kidney hemorrhage due to cortical infarction caused by septic embolism resulting from IE, in association with an anticoagulation status. CASE REPORT A 65-year-old woman who was undergoing anti- coagulation therapy because of mitral valve stenosis and auricular fibrillation presented with an acute-onset left lumbar pain. She was apyretic, with good hemodynamic parameters. Abdominal examination revealed pain in the left flank, no signs of peritoneal irritation and no palpable masses. The hematocrit level was 36.6% on admission, decreasing to 18.9% in the hours that followed, and the quick index was 9%. Ultrasound examination showed an hypoechoic mass in the left renal fossa and CT revealed a large subcapsular hemorrhage (Fig. 1). As the patient’s anticoagulation status prevented any surgical approach, we tried to perform a therapeutic embolism by means of percutaneous arteriography. We could not, however, demonstrate any active bleeding and only viewed a small area of ischemia on the external renal surface. A few hours later, the patient developed hypovolemic shock and a total nephrectomy was performed. Following surgery she suffered cardiac failure and high fever. Echocardiography showed valvular insufficiency and blood cultures confirmed Fig. 1. CT scan showing a large subcapsular hemorrhage in the left kidney. 2003 Taylor & Francis. ISSN 0036–5599 Scand J Urol Nephrol 37 CASE REPORT Scand J Urol Nephrol Downloaded from informahealthcare.com by Universitat Autonoma Barcelona on 10/27/14 For personal use only.
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Transcript of Wunderlich Syndrome as First Manifestation of Infective Endocarditis
Wunderlich Syndrome as First Manifestation of InfectiveEndocarditisJose Miguel Alapont,1 Jose Luıs Pontones,1 Alvaro Gomez-Ferrer,1 Salvador Rivas2 andJuan Fernando Jimenez-Cruz1
From the Departments of 1Urology and 2Pathology, La Fe University Hospital, Valencia, Spain
(Submitted May 17, 2002. Accepted for publication May 31, 2002)
Scand J Urol Nephrol 37: 90–92, 2003
Infective endocarditis (IE) presents with several signs and symptoms that are mainly heart-related and the result ofbacteremia. We describe the case of a woman with severe renal hemorrhage due to a septic embolic cortical infarction, whowas also receiving anticoagulation therapy because of cardiopathy, whose retroperitoneal hematoma was the firstmanifestation of IE.
Key words: infective endocarditis, nephrectomy, Wunderlich syndrome.
Jose Miguel Alapont, Service of Urology, La Fe University Hospital, Avda. Campanar 21, ES-46009 Valencia, Spain. Fax:�34 963862760. E-mail: [email protected]
The predominant manifestations of infective endocar-ditis (IE) are heart-related; however, in 50% of cases(1) the presence of bacteremia reveals signs andsymptoms from any organ affected by septic emboli,such as the spleen, lung, kidney, liver, central nervoussystem (CNS), etc. Spontaneous renal hemorrhage is alife-threatening and diagnostically challenging condi-tion. It is rarely truly spontaneous, being mainly causedby tumors, vascular abnormalities and inflammatorydisorders. Only in rare cases is infarction the cause ofperinephric hematoma (2).
We present the case of a patient with secondarysevere kidney hemorrhage due to cortical infarctioncaused by septic embolism resulting from IE, inassociation with an anticoagulation status.
CASE REPORT
A 65-year-old woman who was undergoing anti-coagulation therapy because of mitral valve stenosisand auricular fibrillation presented with an acute-onsetleft lumbar pain. She was apyretic, with goodhemodynamic parameters. Abdominal examinationrevealed pain in the left flank, no signs of peritonealirritation and no palpable masses. The hematocrit levelwas 36.6% on admission, decreasing to 18.9% in thehours that followed, and the quick index was 9%.Ultrasound examination showed an hypoechoic massin the left renal fossa and CT revealed a largesubcapsular hemorrhage (Fig. 1).
As the patient’s anticoagulation status prevented anysurgical approach, we tried to perform a therapeuticembolism by means of percutaneous arteriography. Wecould not, however, demonstrate any active bleedingand only viewed a small area of ischemia on theexternal renal surface. A few hours later, the patientdeveloped hypovolemic shock and a total nephrectomywas performed. Following surgery she suffered cardiacfailure and high fever. Echocardiography showedvalvular insufficiency and blood cultures confirmed
Fig. 1. CT scan showing a large subcapsular hemorrhage in the leftkidney.
2003 Taylor & Francis. ISSN 0036–5599 Scand J Urol Nephrol 37
CASE REPORT
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the presence of Gram-positive cocci (S. epidermidis).Adequate antibiotics were administered and she wasdischarged from the intensive care unit within a fewdays. Pathology showed a small necrotic area withhemorrhagic cortical infarction due to foci of cocco-bacilli and microabscesses (Figs 2 and 3).
DISCUSSION
IE frequently causes embolism which may involve anyorgan and can cause infarction and abscess. The main
risk factors for developing embolism in IE areStaphylococcus aureus etiology, high fever and doublevalvular and/or mitral valve pathology (3). In IE, thekidney can be affected by one of three mechanisms:focal or diffuse glomerulonephritis caused by inmuno-complex deposits; infarction; and renal abscess. Renalinfarction is usually asymptomatic and less frequentlycauses flank pain. Only rarely does the infarcted arealead to hemorrhage, although anticoagulation statusenables this presentation. In a review of the literaturewe found cases of parenchymal hemorrhage due to
Fig. 2. Small necrotic area onthe external surface of thekidney.
Fig. 3. Coccobacilli in thenecrotic and hemorrhagicarea. Hematoxylin–eosinstaining; originalmagnification �1000.
Scand J Urol Nephrol 37
Wunderlich syndrome as first manifestation of IE 91
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septic embolism in the spleen and CNS (4, 5) but didnot find any cases of renal hemorrhage. Before startingtherapy, two aspects must be considered: the etiologyof the embolism; and the embolism itself and itscomplications. Exceptionally it is necessary to under-take aggressive measures, as in this case.
REFERENCES
1. Millaire A, Leroy O, Gaday V, de Groote P, Beuscart C,Goullard L, et al. Incidence and prognosis of embolicevents and metastatic infections in infective endocarditis.Eur Heart J 1997; 18: 677–84.
2. Libertino JA. Renovascular surgery. In: Walsh PC, RetikAB, Stamey TA, Vaughan ED, Jr, eds. Campbell’surology, 6th edn. Philadelphia, PA: Saunders, 1992:2521–51.
3. Schunemann S, Werner GS, Schulz R, Bitsch A, PrangeHW, Kreuzer H. Embolic complications in bacterialendocarditis. Z Kardiol 1997; 86: 1017–25.
4. Ting W, Silverman NA, Arzouman DA, Levitsky S.Splenic septic emboli in endocarditis. Circulation 1990;82: 105–9.
5. Krapf H, Skalej M, Voigt K. Subarachnoid hemorrhagedue to septic embolic infarction in infective endocarditis.Cerebrovasc Dis 1999; 9: 182–4.
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