Fatal Wunderlich Syndrome During Hemodialysis: A Rare Case and Review of the Literature.

Wunderlich syndrome (WS) is a rare but life-threatening condition characterized by spontaneous, non-traumatic renal hemorrhage, which may present with Lenk's triad. Early recognition and prompt management are crucial to improve prognosis. We report the case of a 49-year-old man with end-stage renal disease secondary to antineutrophil cytoplasmic antibody-associated vasculitis on maintenance hemodialysis who developed sudden left flank pain during a routine hemodialysis session, without preceding trauma. Laboratory evaluation revealed anemia and elevated international normalized ratio. Computed tomography demonstrated an enlarged left kidney with multiple cystic lesions and a large perirenal hematoma extending into the retroperitoneal space, consistent with WS. Despite initial resuscitative measures, the patient rapidly deteriorated into refractory hemorrhagic shock and died before definitive intervention could be performed. This case highlights the potential for rapid deterioration in hemodialysis patients and underscores the importance of early recognition, rapid imaging, and timely multidisciplinary management.