Spontaneous Ruptured Pyomyoma in a Nulligravid Female: A Case Report and Review of the Literature

Abstract

Introduction Pyomyoma, or suppurative leiomyoma, is a rare complication of uterine fibroids. It occurs most commonly in the setting of pregnancy, the immediate postpartum period, or postmenopausal status. It may also arise after recent uterine instrumentation, after uterine artery embolization, or in immunocompromised patients. The most likely cause of pyomyoma is vascular compromise followed by bacterial seeding from direct, hematogenous, or lymphatic spread. Diagnosis is difficult, as the condition is rare, presents with vague symptoms, and is difficult to identify on imaging. Definitive diagnosis is only possible with surgery. Pathology shows a degenerating fibroid with hemorrhage, necrosis, cystic degeneration, and/or inflammatory change. Cultures of the pus contained within often show polymicrobial infection. Case Presentation Our patient is a 24-year-old nulligravid female who presented with a surgical abdomen, fever, hypotension, and leukocytosis. She had no significant prior medical or surgical history, no history of uterine instrumentation, and no history of pelvic infection; she was not currently sexually active at the time of presentation. She was taken to the operating room, where she underwent diagnostic laparoscopy. This showed a ruptured pyomyoma originating in the left broad ligament. She then underwent laparoscopic myomectomy. She was transferred to the ICU intubated; she slowly recovered on IV antibiotics and was discharged home on postoperative day 10. Discussion Pyomyoma is a rare condition and is even rarer in premenopausal patients without recent history of pregnancy or uterine instrumentation. This demonstrates an unusual case of spontaneous pyomyoma in the absence of risk factors, other than a history of known fibroids. Pyomyoma should be considered as a diagnosis in patients with sepsis, history of fibroids, and no other identifiable source of infection.

Septic shock caused by abscess formation inside cystic adenomyosis after responsive treatment of pelvic inflammatory disease

“…However, tuboovarian abscess that arise from pelvic inflammatory disease can progress into sepsis, especially when ruptured [7]. Ruptured tubo-ovarian abscesses, pyometra or pyomyoma that led to sepsis or septic shock have been reported in some case reports or case series [8,9]. In this case, the patient progressed to septic shock without ruptured abscess, and despite successful treatment of pelvic inflammatory disease with intravenous antibiotics for the first five days.…”

Total laparoscopic hysterectomy of an endocervical pyomyoma over previous cesarean section wound

“…Three routes of infection can produce a pyomyoma including direct spreading from the endometrial cavity, the extension of infection from adjacent organs, and hematogenous or lymphatic spreading from occult or apparent infection. [ 1 2 3 4 5 6 7 ] The presented symptoms were fever,[ 1 6 7 ] amenorrhea,[ 2 ] abdominal pain,[ 3 6 ] menometrorrhagia,[ 4 ] hypermenorrhea with severe dysmenorrhea,[ 5 ] and palpated abdominal mass. [ 7 ] This case had experienced menorrhagia for 1 month.…”

“…had reported that the patient was dead due to septic shock. [ 1 ] Myomectomy could preserve fertility in nulliparous women[ 3 6 ] which Pinton et al . showed the patient became pregnant 2 years later after having a myomectomy.…”

“…[ 8 ] The idiopathic pyomyoma mostly occurred in degenerative or necrotic tissue leiomyoma incidentally. [ 1 2 3 4 5 6 7 8 ] Thus, gynecologists must be aware of the possibility of pyomyoma when presented with an abdominal tumor. Pyomyoma is a life-threatening medical condition that can result in death.…”

“…The mode of infection could be ascending, which the most likely cause of pyomyoma is direct infection of bacteria in a vascular compromise, hematogenous, or lymphatic spread. [ 1 2 3 4 5 6 7 ] As pyomyoma is a rare condition, therefore the diagnosis is difficult. This case presented some uncertain symptoms and was difficult to identify from the imaging.…”