A Cough Deteriorating Gross Hematuria: A Clinical Sign of a Forthcoming Life-Threatening Rupture of an Intraparenchymal Aneurysm of Renal Artery (Wunderlich's Syndrome)

Macroscopic hematuria regards the 4% to 20% of all urological visits. Renal artery aneurysms (RAAs) are detected in approximately 0.01%–1% of the general population, while intraparenchymal renal artery aneurysms (IPRAAs) are even more rarely detected in less than 10% of patients with RAAs. We present a case of a 58-year-old woman that came into the emergency room (ER) complaining of a gross hematuria during the last four days. Although in the ER room the first urine sample was clear after a cough episode, a severe gross hematuria began which led to a hemodynamically unstable patient. Finally, a radical nephrectomy was performed, and an IPRAA was the final diagnosis. A cough deteriorating hematuria could be attributed to a ruptured intraparenchymal renal artery aneurysm, which even though constitutes a rare entity, it is a life-threatening medical emergency. 1. Introduction Macroscopic hematuria is a medical condition that the urologist frequently must face in the emergency room (ER) and constitutes the 4% to 20% of all urological visits [1]. Even the most serious cases of gross hematuria that require hospital admission of the patient usually are not life-threatening and in the worst-case scenario can be managed with blood transfusion and perhaps a transurethral operation later in time if the cause is located in the prostate gland or the bladder. Wunderlich’s syndrome is a spontaneous nontraumatic bleeding confined to the subcapsular and/or perinephric spaces in patients with no known underlying cause and constitutes an emergency medical condition [2, 3]. Renal artery aneurysms (RAAs) are detected in approximately 0.01%–1% of the general population, while intraparenchymal renal artery aneurysms (IPRAAs) are even more rarely detected in less than 10% of patients with RAAs [4]. We present a case of a 58-year-old woman that presented in the emergency room of the urology clinic complaining of intermittent gross hematuria but finally became hemodynamically unstable due to rupture of an intraparenchymal aneurysm of the renal artery, and a radical nephrectomy in an emergency basis was performed and saved her life. 2. Case Presentation A 58-year-old woman presented in the ER of the urology clinic complaining of intermittent gross hematuria during the last four days and a mild flank pain during the last hour. The patient also mentioned that the hematuria was deteriorating only during defecating. Arterial hypertension was her only concomitant medical condition. The first sample of urine that we obtained was macroscopically normal with positive dipstick for blood