Abstract Angiomyolipomas (AMLs) are benign renal mesenchymal tumors composed of blood vessels, smooth muscle, and adipose tissue. Large AMLs carry substantial risk of spontaneous hemorrhage. Wunderlich syndrome caused by AML rupture typically presents with acute anemia,hypotension, and perinephric hematoma. AML larger than 4 cm is associated with a risk of hemorrhage. Management includes selective arterial embolization as first-line, nephron-sparing therapy, especially in emergencies. A 60-year-old female with PMH of GERD, DM and HTN presented with sudden-onset 10/10 right hip pain radiating to RUQ and right chest following physical exertion, associated with nausea, SOB, tachycardia, and pallor. Initial workup didn’t reveal ACS. Upon standing, she experienced dizziness followed by witnessed tonic-clonic seizure with urinary incontinence. POC glucose, brain CT/MRI, and EEG were unremarkable. Neurology evaluated as a convulsive syncope. Abdominal ultrasound revealed hepatomegaly with a heterogeneous hypoechoic caudate lobe mass and right pleural effusion. Developed new-onset tachycardia (HR 120-130) while preparing for discharge. Hemoglobin dropped from 10.3 to 6.3, requiring blood transfusion without signs of overt bleeding, raising concern for internal hemorrhage which prompted imaging. CT abdomen/pelvis showed a 5.9 × 8.6 × 7.5 cm right upper pole renal mass (likely angiomyolipoma) with active hemorrhage and perinephric hematoma, and a 3.2 cm hepatic lesion (FNH vs adenoma). Tumor markers (CEA, CA 19-9, CA-125) were normal. Interventional radiology angiography confirmed arterial supply to right renal mass via right middle adrenal artery, and successful embolization was performed without complication. The patient remained hemodynamically stable post-procedure with monitoring and supportive care.In our case, the patient experienced three spontaneous bleeding episodes from AML: the first at home after physical exertion, the second in the ED upon standing resulting in hypotension and a convulsive seizure and the third while preparing for discharge, marked by tachycardia and a rapid hemoglobin drop. Emergent transarterial embolization is associated with rapid hemostasis and often prevents the need for nephrectomy in large series. Angiography can demonstrate abnormal feeders from capsular or adrenal arteries, requiring targeted embolization of these aberrant vessels: identification of such variations is crucial for optimal outcomes and prevention of rebleeding. Postembolization surveillance and transfusion support are essential for monitoring tumor regression and preserving renal function. Multidisciplinary collaboration among hepatology and radiology teams guided imaging surveillance and treatment of hepatic lesions. Prompt recognition and selective embolization of feeder arteries in ruptured large renal AMLS can be lifesaving. This abstract is funded by: No
Aung et al. (Fri,) studied this question.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: