Subserosal pyomyoma in a virgin female: Sonographic and computed tomographic imaging features
Journal
Ultrasound in Obstetrics and Gynecology
Journal Volume
37
Journal Issue
2
Pages
247-248
Date Issued
2011
Author(s)
Liu H.-S.
Abstract
A 42-year-old sexually inactive woman presented to our emergency department with worsening abdominal pain and high fever of 1 day's duration. During the previous month, she had had occasional mild lower abdominal pain, but without other symptoms. Her past medical history was unremarkable except for a myomectomy 10 years previously. Physical examination revealed diffuse abdominal tenderness with rebound. Laboratory data were notable for a leukocyte count of 42 880 per mm3 with a left shift. Pelvic sonography showed a large unilocular cystic structure in the upper pelvis measuring 9.0 �� 8.0 �� 6.5 cm that demonstrated internal debris and a hyperechoic thick wall (Figure 1a). Contrast-enhanced computed tomography revealed a large cystic mass with a thick wall, which was posterior to and superior to the uterus (Figures 2a and c). Bilateral ovarian cysts were also noted (Figure 2b). (a) Preoperative ultrasound image showing a large unilocular cystic structure in the upper pelvis that demonstrated internal debris and a hyperechoic thick wall. (b) Pelvic ultrasound image 4 months after surgery showed that the size of the subserosal fibroid had decreased to 3 cm. M, tumor mass; U, uterus. Computed tomography images showing a thick-walled, 9-cm cystic mass within the upper pelvis, superior to the uterus. (a) Coronal view: white arrows indicate the cystic mass, black arrow indicates the uterus; (b) coronal view: arrows indicate bilateral ovarian cysts; (c) axial view of the pelvic tumor. Even in the absence of risk factors for ascending genital-tract infection, tubo-ovarian abscess was still the primary consideration based on the laboratory results and imaging findings. Antibiotic therapy was started immediately, but the patient's symptoms persisted. The following day an exploratory laparotomy revealed purulent material in the peritoneal cavity and a thick-walled pelvic mass containing purulent material. The mass was found to originate from the posterior wall of the uterus. Myomectomy could not be performed because the mass had severe adhesions. Instead, a tumor incision, marsupialization and drainage were performed. Microscopically, the mass consisted of fibrous tissue and smooth muscle cells, along with granulation tissue and chronic inflammation. No evidence of malignancy was noted. The patient had an uneventful recovery and was discharged within a week after surgery. Pelvic ultrasound 4 months after surgery showed that the size of the mass had decreased to 3 cm (Figure 1b). She remained well at the 12-month follow-up visit. Pyomyoma, or a suppurative leiomyoma, is a rare and potentially fatal complication of uterine leiomyoma. Only 21 cases have been reported since 19451-10. Most cases occur during pregnancy or after menopause, and are caused by ascending genital-tract infection. To our knowledge, this is the first case of pyomyoma described in a healthy premenopausal female and unrelated to any focus of infection. Only surgical treatment is life saving for patients with pyomyoma2, 3. Clinical suspicion and recognition of the sonographic features may prompt surgical intervention; however, published case reports have described only nonspecific sonographic findings, which are not diagnostic. Most reports mention an enlarging heterogeneous pelvic mass with solid and cystic components3-6. Nguyen and Gruenewald9 stated that the presence of gas in uterine leiomyoma is highly suggestive of pyomyoma. In the present case the diagnosis was delayed because the patient had never had sexual activity and her subserosal pyomyoma presented as a large unilocular cystic mass resembling a tubo-ovarian abscess. In conclusion, the diagnosis of pyomyoma is difficult because of its diverse presentation and lack of characteristic imaging features. Thus, we suggest that in patients with a thick-walled pelvic mass and unexplained fever or abdominal pain, pyomyoma should be included in the differential diagnosis. H.-S. Liu*, C.-H. Chen*, * Department of Obstetrics and Gynecology, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
SDGs
Other Subjects
adult; case report; color ultrasound flowmetry; computer assisted tomography; echography; female; human; leiomyoma; letter; methodology; radiography; rare disease; treatment outcome; uterus cancer; Adult; Female; Humans; Leiomyoma; Rare Diseases; Tomography, X-Ray Computed; Treatment Outcome; Ultrasonography, Doppler, Color; Uterine Neoplasms
Type
letter