|Year : 2015 | Volume
| Issue : 1 | Page : 36-39
Septic uterine myoma: A case report
AO Ojabo1, AG Adesiyun2, DI Ifenne1, N Ameh2, S Hembar-Hilekan1, AM Durosinlorun3
1 Departments of Obstetrics and Gynaecology, College of Health Sciences, Benue State University, Makurdi, Nigeria
2 Departments of Obstetrics and Gynaecology, Ahmadu Bello University, Zaria, Nigeria
3 Departments of Obstetrics and Gynaecology, Shehu Mohammed Kangiwa Medical Center, Kaduna, Nigeria
|Date of Web Publication||13-Mar-2015|
A O Ojabo
Department of Obstetrics and Gynaecology, College of Health Sciences, Benue State University, Makurdi - 970 001
Source of Support: None, Conflict of Interest: None
Pyomyoma (suppurative leiomyoma) is a rare disease that can result in very serious complications. Though most cases have occurred in pregnant or postmenopausal women with a predisposing factor, we present a case that apparently presented spontaneously. A young nulligravid woman presented with a history of abdominal pain and swelling of 2 weeks duration which became worse despite use of potent broad-spectrum antibiotics. She had no fever or predisposing factors, but had history of leiomyoma. Ultrasonographic scan showed an enlarged uterus with a solitary large mass. Internal heterogeneous echogenicity was noted within the mass in the anterior wall of the body of the uterus. With a clinical impression of degenerated leiomyoma, she underwent abdominal myomectomy. However, intraoperative findings showed a leiomyoma with abscess formation. The postoperative course was uneventful. Pyomyoma is rare and may be difficult to diagnose clinically, especially in women with a nonspecific clinical presentation. A strong clinical suspicion and prompt surgical intervention with the use of broad-spectrum antibiotics can be lifesaving.
Keywords: Abdominal pain, hysterectomy, leiomyoma, myomectomy, pyomyoma, septic uterine myoma
|How to cite this article:|
Ojabo A O, Adesiyun A G, Ifenne D I, Ameh N, Hembar-Hilekan S, Durosinlorun A M. Septic uterine myoma: A case report
. Arch Int Surg 2015;5:36-9
| Introduction|| |
Leiomyomata are very common benign tumors of the uterus and female pelvis. Myomas have been reported in 25% of Caucasian American women and 50% of African American women.  Among Nigerian women, an incidence rate of up to 80% has been reported.  The true incidence is unknown, but description of 50% has been found in postmortem examinations.  Pyomyoma (suppurative leiomyoma) are a rare complication resulting from infarction and infection of leiomyoma. ,,,,
Without a strong clinical suspicion and surgical intervention, fatalities may occur. This report documents a pyomyoma that presented as an acute abdomen in a woman who was previously known to have a huge myoma. This case is unique because the patient had no history of a recent pregnancy, she had not undergone vaginal or uterine instrumentation, she was not perimenopausal, and did not undergo a hysterectomy at the time of exploratory laparotomy. About 4 months after undergoing abdominal myomectomy, her normal cyclical menstruation had been reestablished.
| Case Report|| |
The patient was a 33-year-old nulligravida who presented to our clinic with a 3 day history of severe lower abdominal pain with an abdominal mass, nausea, vomiting, fever, and history of a huge myoma. She denied sexual activity, placement of foreign body or instrumentation of the uterus prior to presentation to our health center. On examination, her vital signs were: Temperature 37.4C, pulse rate 104 beats/min, blood pressure (BP)-110/70 mmHg, and respiratory rate 18/min.
Abdominal examination revealed a 20-week size tender midline mass, no ascites, palpably enlarged liver and spleen, and no costovertebral tenderness. Pelvic examination showed a 24 cm tender midline mass arising from the pelvis and attached to the uterus. No other adnexal masses were palpable. Renal and liver function tests were normal. A complete blood count revealed hemoglobin of 10.6 g/dl and a leukocyte count of 36,000 cells per mm.  Abdominal and pelvic ultrasound revealed a large uterine mass 15.3 cm × 11.5 cm, with an eccentric cystic area measuring 8.2 cm × 5.8 cm. Both ovaries appeared normal. The uterine cavity was empty and there was no ascites or fluid in the pouch of Douglas. A diagnosis of myoma with cystic degeneration was made. The patient was commenced on intravenous fluids, metronidazole infusion, ceftriaxone, and intramuscular paracetamol. Blood was cross-matched. Despite continuing these medications for 48 h, the patient's condition did not improve and she had a surgical exploration on the 3 rd day of admission.
The findings were a uterus enlarged to about 20 weeks by a solitary myoma, clean pelvis devoid of adhesions, normal ovaries, and tubes. The myoma was carefully enucleated, but when a myoma screw was applied to exert traction on the myoma to ease removal, an abscess cavity was entered and foul-smelling, thick, yellow purulent exudates started escaping through the hole created by the myoma screw. The uterus was carefully isolated with abdominal packs and contamination of the abdominal cavity was prevented. The myoma was dissected from the uterus [Figure 1]. The myoma cavity was carefully repaired in several layers using absorbable sutures of appropriate size. The peritoneal cavity was irrigated with warm normal saline and the abdomen closed. The patient's postoperative course was uneventful. Intravenous antibiotics were continued for 5days and converted to oral medications for a further 3 days. She was discharged home on the 8 th postoperative day.
The pathology specimen was a fibroid mass with pale areas measuring 19 ΄13 ΄8 cm and weighed 2,470g [Figure 2]. The cut-surface revealed an area that contained yellow green pus with necrotic tissue and6cm thick, firm, white-to-pink capsules [Figure 3]. The histological diagnosis was pyomyoma with acute and chronic inflammation and abscess formation; leiomyoma with suppuration. Aerobic culture reveals Staphylococcus spp. At the 6 th week postoperative follow-up visit, the patient reported normal menses.
|Figure 3: Septic myoma cut open. Note the pale colored area which is the pus within the cavity of the myoma|
Click here to view
| Discussion|| |
Pyomyoma is a very rare disease and was first described in the literature in 1871 and by 1945, about 45 cases have been described.  Between 1945 and 2012, an additional 23 cases (including this case) have been described. ,, Thus, the incidence has reduced dramatically in the post-antibiotic.  Leiomyomas can be infected by bacterial seedling of necrotic foci. This occurs due to vascular insufficiency in postmenopausal patients or hemorrhage and necrosis during pregnancy. It can also occur following gynecological procedures such as insertion or removal of intrauterine contraceptive device (IUCD) and uterine artery embolization ,,,, and termination of pregnancy.  Other associated causative factors include preexisting uterine or cervical infections at the time of the procedure, advanced age, immunocompromised state,  and intravenous drug use. 
The route of infection in these patients includes direct spread from the endometrial cavity, the adnexa or the bowel; hematogenous or lymphatic spread; or spread from a remote infectious source.  In postmenopausal women, it is thought to be related to vascular pathology such as hypertension, atherosclerosis, or diabetes.  The proposed mechanism for the development of pyomyoma in these patients is uterine ischemia caused by decreased vascular supply to the uterus. Diabetes, in particular, increases susceptibility to infection. Infection can exacerbate the diabetes and increase blood sugar levels, thus creating a vicious cyclce.  The infected leiomyoma can manifest as a painful abdominal or pelvic mass, as bacteremia without a clear source or as an acute abdomen due to intra-abdominal rupture. Review of the literature confirms the difficulty in early diagnosis of pyomyomas secondary to mild or nonspecific symptoms. ,
Pyomyomas, following pregnancy or abortion or gynecological procedures, usually develop insidiously over days to weeks as a result of extension of infection from the uterine cavity, from adjacent structures or via hematogenous or lymphatic spread. In our patient, the pyomyoma developed without any apparent cause. Other authors have also described cases in which no apparent precipitating factor was detected. , Organisms reported to cause pyomyomas include Clostridium sp, Staphyloccocus aureus, Streptococcus milleri, Streptococcus hemolyticus, Proteus sp, Serratia marcescens, Actinomyces myeri, Enterococcus faecalis, and Staphylococcus agalactiae. ,,,, In this patient, the microbial agent isolated was Staphylococcus aureus. This could be due to previous pelvic inflammatory disease (PID), though the patient denied history of sexual activity in the weeks preceding the onset of ill-health.
The admitting diagnosis for this patient was degenerating myoma. It is very difficult to differentiate acute degeneration from infection clinically, as signs and symptoms may be nonspecific. It is evident from the literature that these cases are often missed or diagnosis is delayed, due to the above difficulty.  The differential diagnosis of pyomyoma includes any pelvic mass associated with signs of infection such as pyometra, tuboovarian abscess, and adnexal mass or malignancy.  In pregnant women, the differential diagnosis expands to threatened or spontaneous abortion, infected ectopic pregnancy, and degeneration of leiomyoma. Magnetic resonance imaging (MRI) and computed tomography (CT)-scan has been used recently to accurately diagnose pyomyoma preoperatively.  This was not carried out on our patient because of lack of availability. Conservative treatment for degenerating myoma includes analgesics, intravenous fluids, and bed rest. It may be worthwhile considering prophylactic use of antibiotics, especially in pregnancy, in the conservative management of fibroid degeneration.
This case represents one of the few reported pyomyoma that required abdominal exploration and myomectomy with retention of the uterus, Fallopian tube More Detailss, and ovaries for future fertility as the patient was young. Majority of women who present with pyomyoma undergo total abdominal hysterectomy (TAH) with bilateral salpingo-ophorectomy (BSO), which is regarded as the standard treatment of choice. ,,, This procedure is appropriate for most of these women because they are either past the reproductive age, are close to menopause or are elderly. ,,,
Though pyomyomas are rarely reported, our case should increase the index of suspicion in populations with leiomyomas, unexplained fevers, and abdominal pain. ,, This case has demonstrated that the presence of pyomyoma does not invariably require a hysterectomy as timely surgical intervention and use of broad-spectrum antibiotics will in most cases lead to a resolution of the infective process. Thus, the patient had her menstrual and reproductive function preserved as she intended to have a family of her own later. Failure to institute appropriate surgical treatment can result in mortality and morbidity. This is especially important as mortality rate of between 13.6 and 21% have been reported. ,
However, pyomyoma should be considered in the setting of pregnancy, known large submucosal leiomyomas with cystic development, unexplained fever, and abdominal pain; particularly if preceded by a genital tract infection. This case did not have fever or history of preceding pregnancy or uterine instrumentation, which makes this patient a rare case. Distinguishing pyomyoma from nonsuppurative disease is important, because the definitive treatment is surgery. Isolated sonographic findings may be nonspecific, but the presence of gas is highly suggestive. Clinical suspicion as well as recognition of the sonographic features and prompt treatment can be potentially lifesaving.
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[Figure 1], [Figure 2], [Figure 3]