A Case of Spontaneous Renal Haemorrhage (Wunderlich Syndrome) in an Anticoagulated Patient

Spontaneous renal haemorrhage is a rare but severe condition known as Wunderlich syndrome (WS). The classic presentation includes sudden-onset flank pain, a palpable flank mass and hypovolaemic shock (Lenk’s triad). WS can be due to neoplasms, vascular diseases, cystic rupture, coagulopathies and infections. A contrast-enhanced CT scan of the abdomen is mandatory for diagnosis. Surgery is reserved for haemodynamically unstable patients and those with neoplastic disease. We describe a case of WS in an anticoagulated patient with chronic atrial fibrillation, diabetes mellitus type 2 and hypertension, who developed acute renal failure and severe anaemia, that completely resolved with conservative treatment and discontinuation of anticoagulation therapy.

Kounis syndrome: from an unexpected case in the Emergency Room to a review of the literature

Kounis syndrome (KS) is a coronary syndrome in the setting of allergic/anaphylactic reactions and can be classified in three variants: vasospastic allergic angina (type I), allergic myocardial infarction (type II) and stent thrombosis (type III). The early diagnosis is of paramount importance for the correct management and the prognosis, being KS a life-threatening emergency condition. KS is not uncommon, but it is frequently unrecognized or undiagnosed in virtue of its broad clinical manifestations. The diagnosis should be based on the combination of cardiovascular and allergic/anaphylactic clinical symptoms and signs, as well as on laboratory, electrocardiographic, echocardiographic, and angiographic evidence. ECG monitoring, cardiac enzymes and troponin are mandatory to confirm or exclude KS in a patient with subclinical or clinical, acute, or chronic allergic reactions. Nevertheless, the treatment is a real challenge for the emergency clinicians because guidelines have not been established yet, and the therapy is based on the variant type. We herein report the case of type I KS in a woman with no prior history of allergy, admitted to our emergency department for abdominal pain, nausea and hematochezia. Starting from this case we conducted a systematic search of the following databases: PubMed, Google Scholar, Science Direct, Medline, using the keywords of “Kounis syndrome”, “coronary spams”, “cardiac arrest”, “sudden death”, “allergy”, and “anaphylaxis”. The main purpose of this review is to remind emergency clinicians to keep a high index of suspicion regarding KS when dealing with patients with allergic reactions or anaphylaxis to promptly identify and correctly manage KS. (www.actabiomedica.it)

A case of hematuria and vomiting in the emergency room: Never forget the emphysematous pyelonephritis

We describe the case of a 68-year-old man with a known history of hypertension and diabetes mellitus presented to our Emergency Department, complaining of hematuria and vomiting in the last 12 hours, stypsis and urinary incontinence in the last week, and worsening hyporexia in the last 6 months. Bedside ultrasound documented a slight right pleural effusion with B lines in the middle and basal right field, gastrectasis, dilated fluid-filled bowel loops, potential signs of gas in the upper right quadrant, grade 3 bilateral hydronephrosis, and bladder globe. Abdominal CT scan confirmed the bilateral hydroureteronephrosis and showed the right kidney with Emphysematous Pyelonephritis (EPN) with extension into the perinephric and muscular planes for 24 cm, and initial EPN in the left kidney. A RT-PCR nasopharyngeal swab for SARS CoV-2 was negative. A diagnosis of ileum paretic, acute renal failure and urosepsis due to EPN was made.

The clinical spectrum of pulmonary thromboembolism in patients with coronavirus disease-2019 (COVID-19) pneumonia: A European case series

Purpose

To describe the clinical characteristics and outcomes of coronavirus disease-2019 (COVID-19)-associated pulmonary thromboembolism (PTE).

Materials and methods

A case series of five patients, representing the clinical spectrum of COVID-19 associated PTE. Patients were admitted to four hospitals in Germany, Italy, and France. Infection with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) was confirmed using a real-time reverse transcription polymerase chain reaction test.

Results

The onset of PTE varied from 2 to 4 weeks after the occurrence of the initial symptoms of SARS-CoV-2 infection and led to deterioration of the clinical picture in all cases. PTE was the primary reason for hospital admission after a 2-week period of self-isolation at home (1 patient) and hospital readmission after initial uncomplicated hospital discharge (2 patients). Three of the patients had no past history of clinically relevant risk factors for venous thromboembolism (VTE). Severe disease progression was associated with concomitant increases in IL-6, ferritin, and D-Dimer levels. The outcome from PTE was related to the extent of vascular involvement, and associated complications.

Conclusion

PTE is a potential life-threatening complication, which occurs frequently in patients with COVID-19. Intermediate therapeutic dose of anticoagulants and extend thromboprophylaxis are necessary after meticulous risk-benefit assessment.

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Pulnonary thromboembolism (PTE) is a frequent life-threatening complication in patients with COVID-19.

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The onset of PTE varies from 2 to 4 weeks after the occurrence of the initial symptoms.

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PTE may occur in patients without past history of risk factors for venous thromboembolism and in those receiving standard prophylactic anticoagulation.

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Intermediate therapeutic dose of anticoagulants and extend thromboprophylaxis are necessary in these patients after meticulous risk-benefit assessment.

Pulmonary embolism in patients with coronavirus disease-2019 (COVID-19) pneumonia: a narrative review

BACKGROUND

Preliminary reports have described significant procoagulant events in patients with coronavirus disease-2019 (COVID-19), including life-threatening pulmonary embolism (PE).

MAIN TEXT

We review the current data on the epidemiology, the possible underlying pathophysiologic mechanisms, and the therapeutic implications of PE in relation to COVID-19. The incidence of PE is reported to be around 2.6-8.9% of COVID-19 in hospitalized patients and up to one-third of those requiring intensive care unit (ICU) admission, despite standard prophylactic anticoagulation. This may be explained by direct and indirect pathologic consequences of COVID-19, complement activation, cytokine release, endothelial dysfunction, and interactions between different types of blood cells.

CONCLUSION

Thromboprophylaxis should be started in all patients with suspected or confirmed COVID-19 admitted to the hospital. The use of an intermediate therapeutic dose of low molecular weight (LMWH) or unfractionated heparin can be considered on an individual basis in patients with multiple risk factors for venous thromboembolism, including critically ill patients admitted to the ICU. Decisions about extending prophylaxis with LMWH after hospital discharge should be made after balancing the reduced risk of venous thromboembolism (VTE) with the risk of increased bleeding events and should be continued for 7-14 days after hospital discharge or in the pre-hospital phase in case of pre-existing or persisting VTE risk factors. Therapeutic anticoagulation is the cornerstone in the management of patients with PE. Selection of an appropriate agent and correct dosing requires consideration of underlying comorbidities.