Varying clinical presentations of nutcracker syndrome: a case report

The term nutcracker syndrome was initially established in 1972 to refer to the compressive effects on the left renal vein due to a narrow angle between the abdominal aorta and the superior mesenteric artery. Although the precise prevalence of nutcracker syndrome remains unknown, an incidence of up to 4% has been described in patients presenting with hematuria. The peak age of incidence is between 10 and 30 years, and it is equally prevalent among both genders, though earlier studies showed a predominantly female preponderance. About 70-80% of patients present initially with hematuria, though left flank pain and proteinuria may also be presenting symptoms. A high index of suspicion and appropriate imaging often helps in aiding diagnosis.

In this case report, we present here two South Asian young females aged 23 and 30 years old. They presented with gross painless hematuria of a duration of 2 years (Case 1) and nonspecific symptoms of abdominal pain (Case 2), and they were diagnosed with nutcracker syndrome on investigation. Both patients were diagnosed by computed tomography angiography with defined aortomesenteric angles diagnostic of nutcracker syndrome. Patient 1 underwent saphenous venous bypass grafting and repositioning of left renal vein with symptomatic improvement, while patient 2 was managed conservatively and continues to be on close follow-up. In addition, we present a brief review of this syndrome so that better insight is obtained regarding diagnosis and management.

The diagnosis of nutcracker syndrome needs to be considered in patients who present with unexplained hematuria or proteinuria. Diagnosis by appropriate imaging studies is necessary, and treatment is dictated by the severity of symptoms. Surgical therapy remains the front-line treatment; however, endovascular techniques are becoming favored owing to advancements in stent technology.