Pyomyoma: A Case Report

Aust NZ J Obstet Gynaecol 1999; 39: 4:520-521

Pyomyoma: A Case Report Bipin G ~ p t a ' MD, ? ~ Alka Sehga12,4MD, Ravinder K a ~ r *MD , ~ and Sarla M a l h ~ t r aMD ~,~ Departments of Obstetrics and Gynaecology4 and Radiology5, Government Medical College, Chandigarh, India

EDITORIAL COMMENT We accepted this case f o r publication because, although rare, it is interesting and has been associated with a high fatality rate unlike pyometra where the pus is usually sterile on culture. One of the reviewers wondered whether it was wise to aspirate such a tumour but since this patient survived treatment uneventfully it may be that the preoperative knowledge of the abscess provided an advantage at least in suggesting the need f o r antibiotic therapy. The editor has seen a number of cases of submucous jibroids associated with infection, especially when they have prolapsed through the cervix into the vagina, but he has never seen a case of a pyomyoma as described here. N.B.

We present a rare case of spontaneously occurring massive pyomyoma in a postmenopausal woman. Only surgical intervention is lifesaving in this otherwise fatal condition.

CASE REPORT A 75 year old postmenopausal woman was referred to us from the medical outpatients department where she had reported with a history of low grade fever off and on for 15 days. She was found to have a huge palpable abdominal mass. The fever was not associated with chills and rigors and there were no other localizing signs and symptoms. On general physical examination the patient was emaciated and poorly built with mild pallor and an irregular, nontender mass with restricted mobility and variegated consistency was felt arising from the pelvis and occupying the entire abdomen. The spleen and liver were not palpable and there was no signs of ascites. On local examination the cervix was atrophic and pushed high up and the abdominal mass was palpable through all the fornices. The patient was investigated which revealed a total leucocyte count of 14x109/L with 70% neutrophils. Renal and liver function tests and X-ray of the abdomen and chest were normal. On abdominal ultrasound examination a mass of heterogenous echogenicity about 25x25cm, with a large cystic area 8x8cm was seen (figure 1). The uterus and ovaries could not be seen separately. The clinical impression was that of a huge fibroid 1. Reader. 2. Senior Lecturer. 3. Professor. Address for correspondence: Dr Bipin Cupta, # 1205, Sector 11 Panchkula (Haryana) India 1341 12.

uterus with cystic degeneration, and a differential diagnosis of an ovarian tumour was also entertained. A fine needle aspiration from 1 site aspirated 5mL of frank pus which on smear showed a large number of polymorphonuclear leucocytes. Aspiration from the second site of the mass was suggestive of benign leiomyoma. The patient was started on broad spectrum antibiotics and taken to theatre for laparotomy. Intraoperative findings showed the uterus to be replaced by a huge fibroid measuring 3Ox25cm (4.3kg) and both ovaries were atrophied. Total abdominal hysterectomy with bilateral salpingooophorectomy was performed. On cut-section there were patches of cystic and hyaline degeneration and one locule about lOxlOxlOcm in size, contained about 1 litre of greenish pus, which on culture grew Staphylococcus aureus. The patient responded to the surgery and antibiotic therapy. The postoperative period was uneventful and the patient was discharged on the tenth day, after removal of sutures.

DISCUSSION Pyomyoma has been of rare occurrence in the postantibiotic era. While approximately 75 cases of pyomyoma were reported between 187 1- 1945, only 13 cases (including ours) have been reported thereafter (1-3). The pathology is mostly related to pregnancy (6 of 13), probably when the rapid growth makes myomas prone to degeneration and superadded infection. Ascending infection can accompany pregnancy termination both spontaneous or induced. The remaining 7 cases were related to the gynaecological infections, as in our patient, occuring in postmenopausal women. In these women the incidence of associated vascular pathology (diabetes and hypertension) was high. Associated atherosclerosis is thought to contribute to the degeneration, necrosis and infection (1). There are

BIPINGUITAET AL

Figure 1: Ultrasonogram showing a leiomyoma with a large cystic area.

reports of single or multiple abscesses varying from 7 to 15cm size in these cases. The mode of infection could be ascending infection, extension from the adnexa, lymphatic spread or even haematogeneous spread from a distant source. The majority of the involved cases (5 of 7) initially had an insidious course but could have a fatal outcome if intervention was delayed. Three of these 7 patients died while awaiting surgery or in the immediate postoperative period. Pyoperitonitis, septicaemia and adult respiratory distress are the life-threatening

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complications associated with this pathology. Even in the present era of broad spectrum antibiotics, the definitive treatment of this condition remains surgery which, if delayed, can result in the life-threatening complications listed above. Our patient was neither diabetic nor hypertensive and did not have any history of intervention to suggest a possible portal of infection. The outcome is adverse in these cases because the diagnosis is often missed or delayed due to the rarity of the condition. As surgery is the only definitive treatment, prompt diagnosis can be lifesaving. In spite of the rarity of the condition, in a patient with fibroids with pyrexia of unknown origin, a high index of suspicion could help in early diagnosis and prompt treatment of the otherwise fatal condition of pyomyoma.

References 1. Greenspoon JS, Ault M, James BA, Kaplan L. Pyomyoma associated with polymicrobial bacteremia and fatal septic shock case report and review of the literature. Obstet Gynecol Sum 1990; 45: 563-569. 2. Prahlow JA, Cappellari JO, Washbum SA. Uterine pyomyoma as a complication of pregnancy in an intravenous drug user. South Med J 1996; 89: 892-895. 3. Tobias DH, Koenigsberg M, Kogan M, Edelrnan M, Levgur M. Pyomyoma after uterine instrumentation a case report. J Reprod Med 1996; 41: 375-378.