Year :
2023
| Month :
September
| Volume :
17
| Issue :
9
| Page :
TJ01 - TJ02
Full Version
Spontaneous Ruptured Pyomyoma in a Nulligravida Female
Published: September 1, 2023 | DOI: https://doi.org/10.7860/JCDR/2023/64694.18374
Revathi Rajagopal, Senthil Kumar Aiyappan, Anuradha Murugesan, Shakthi Manisekaran Manimozhi
1. Junior Resident, Department of Radiodiagnosis, SRM Medical College Hospital and Research Centre, SRMIST, Kattankulathur, Chengalpattu, Tamil Nadu, India.
2. Professor and Head, Department of Radiodiagnosis, SRM Medical College Hospital and Research Centre, SRMIST, Kattankulathur, Chengalpattu, Tamil Nadu, India.
3. Professor and Head, Department of Obstetrics and Gynaecology, SRM Medical College Hospital and Research Centre, SRMIST, Kattankulathur, Chengalpattu, Tamil Nadu, India.
4. Senior Resident, Department of Obstetrics and Gynaecology, SRM Medical College Hospital and Research Centre, SRMIST, Kattankulathur, Chengalpattu, Tamil Nadu, India.
Correspondence Address :
Senthil Kumar Aiyappan,
Professor and Head, Department of Radiodiagnosis, SRM Medical College Hospital and Research Centre, SRMIST, Kattankulathur, Chengalpattu-603203, Tamil Nadu, India.
E-mail: asenthilkumarpgi@gmail.com
Abstract
A 41-year-old unmarried nulligravida female presented with complaints of dysuria and intermittent fever for one week. There was no history of menstrual symptoms, uterine instrumentation, or uterine artery embolisation. The patient was a known case of type 2 diabetes and was on insulin treatment. There was no history of hypertension, bronchial asthma, tuberculosis, or thyroid disorder. On examination, the patient had a fever (99.8o F) and stable vital signs. Abdominal examination revealed a uterus size equivalent to 16 weeks of pregnancy. Blood investigations showed leukocytosis with a predominance of neutrophils (Total White Blood cells (WBC) count: 22,370 cells/cu mm with 83% neutrophils) and an elevated Erythrocyte Sedimentation Rate (ESR) of 96 mm/hr. HbA1c was 12.1%, indicating uncontrolled diabetes with an estimated average blood sugar level of 301 mg/dL. A pap smear was negative for intraepithelial lesion or malignant cells. Abdominal ultrasound revealed an enlarged uterus measuring 11.5×9.3×7.9 cm with an anterior wall fibroid measuring approximately 8.3×8.4 cm in the fundal region (Table/Fig 1)a,b. Abdominal and pelvic MRI showed a large heterogeneous lesion with cystic areas measuring 9.0×9.2×8.8 cm in the right antero-lateral myometrial wall (Table/Fig 2)a-d.
Based on the ultrasound and Magnetic Resonance Imaging (MRI) findings, the possibility of a large anterior wall subserous fibroid with cystic degeneration was considered. The patient underwent surgery, revealing an infected degenerated fibroid in the anterior wall of the uterus with pus drainage, indicating rupture. Foul-smelling pus of approximately 250-300 mL was drained from the peritoneal cavity. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. An intraperitoneal drain was placed, and the skin was closed with 2-0 ethilon. No intraoperative or post-operative complications occurred, and the specimen was sent for histopathological analysis (Table/Fig 3)a,b. Histopathology revealed a leiomyomatous uterus with degenerative changes. Culture and sensitivity analysis of the pus showed occasional pus cells, but no organisms were observed.
Keywords
Dysuria, Fibroid, Leiomyomatous uterus
Discussion
Pyomyoma or suppurative leiomyoma is a rare condition that occurs when an existing leiomyoma becomes infected. The classic triad of symptoms includes abdominal pain, a history of leiomyoma, and sepsis without an obvious origin of bacteremia (1),(2),(3). It usually occurs in pregnancy, post-menopausal women, following uterine instrumentation, or uterine artery embolisation [4,5]. The typical cause is secondary infection in necrotic areas of the fibroid, either due to overgrowth or vascular insufficiency. The present case involved a nulligravida patient with no previous uterine instrumentation or uterine artery embolisation, making it difficult to suspect pyomyoma preoperatively. Consequently, it was initially misdiagnosed as cystic degeneration of the fibroid. Moreover, there were no air foci within the fibroid that could have indicated a secondary infection. In this case, since surgery took place five days after the MRI, the rupture of pyomyoma and the presence of pus in the peritoneal cavity were not detected by the MRI. Imaging alone poses challenges in diagnosing pyomyoma unless air is present within the fibroid. A similar case was reported by Read S and Mullins J, in nulligravida females, although their case involved a broad ligament fibroid, whereas the present case involved a subserous fibroid (1). Another case reported by Bagga R et al., described pyomyoma causing post-abortal fever (2). De Maoi A and Doyle M, reported a pyomyoma causing postpartum fever (3). Surgery serves as the definitive method for diagnosis and treatment. Therefore, in patients with fibroids and fever without any apparent source of sepsis, especially in diabetic patients, surgeons should consider the possibility of pyomyoma (2).
Reference
| 1. | Read S, Mullins J. Spontaneous ruptured pyomyoma in a nulligravid female: A case report and review of the literature. Case Rep Obstet Gynecol. 2018;2018:1026287. Doi: 10.1155/2018/1026287.
[ CrossRef] [ PubMed] | 2. | Bagga R, Rai R, Kalra J, Saha PK, Singh T. An unusual cause of postabortal fever requiring prompt surgical intervention: A pyomyoma and its imaging features. Oman Med J. 2017;32(1):73-76.
[ CrossRef] [ PubMed] | 3. | DeMaio A, Doyle M. Pyomyoma as a rare source of postpartum sepsis. Case Reports in Obstetrics and Gynecology. 2015;2015:263518. https://doi. org/10.1155/2015/263518.
[ CrossRef] [ PubMed] | 4. | Obele CC, Dunham S, Bennett G, Pagan J, Sung LY, Charles HW. A case of pyomyoma following uterine fibroid embolization and a review of the literature. Case Rep Obstet Gynecol. 2016;2016:9835412. Doi: 10.1155/2016/9835412.
[ CrossRef] [ PubMed] | 5. | Rezai S, Elmadjian M, Hastings A, Ferreira, K, Folterman C, Astill N, et al. Pyomyoma following uterine artery embolization (UAE)-dual case report and review of literature. Obstet Gynecol Int J. 2015;4(1):33-37. [ CrossRef] |
DOI: 10.7860/JCDR/2023/64694.18374
Date of Submission: Apr 13, 2023
Date of Peer Review: Jun 10, 2023
Date of Acceptance: Jun 20, 2023
Date of Publishing: Sep 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 17, 2023
• Manual Googling: Jun 12, 2023
• iThenticate Software: Jun 17, 2023 (4%)
ETYMOLOGY: Author Origin
EMENDATIONS: 5
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