Pyomyoma after a cesarean section

Abstract

Pyomyoma, or suppurative leiomyoma, is a rare but serious complication of leiomyomas. Since 1945, only 14 cases have been reported, and the mortality was 21% (1). The high mortality probably reflects delayed diagnosis. Most cases occurred related to pregnancy or menopause, and were caused by ascending infection from the lower genital tract. Here we report a woman who developed Escherichia coli bacteremia and wound infection and Candida parapsilosis pyomyoma. This is the first case that pyomyoma was caused by Candida. Magnetic resonance imaging (MRI) of pyomyoma, which has never been reported, is also presented here. A 33-year-old woman with multiple leiomyomas was admitted at 30 weeks of pregnancy because of preterm uterine contractions. These leiomyomas grew in size during pregnancy with the largest one being 5.9 × 4.8 cm at the time of admission. A cesarean section was performed 9 days later, owing to severe variable decelerations after rupture of membranes. Shortly after returning to the ward, massive vaginal bleeding developed and hypovolemic shock ensued. The woman was resuscitated with aggressive blood transfusion, oxytocin and ergonovin. The woman returned 6 days after the cesarean section because of fever and abdominal pain. Her wound was found to be infected and was opened and cleansed. Wet-to-dry dressings were applied and combination antibiotics administered. Four days later, the patient suffered chills and fevers up to 41 °C. Wound cultures and blood cultures grew E. coli. MRI identified leiomyoma necrosis and pus in front of the uterus (Fig. 1). Because fever persisted and she developed septic shock, a laparotomy was performed. A leiomyoma at the low anterior wall ruptured on opening of the abdomen and drained pus, cultures from which grew C. parapsilosis. A hysterectomy was then performed, and tissue pathology identified endometritis and necrosis of all the leiomyomas, with massive inflammation in the ruptured one. A sagittal T1-weighted MR image after contrast shows decreased signal intensity in all leiomyomas with irregular contour and heterogeneous intensity in the low anterior one (arrowheads), which contained pus. Postoperatively fever subsided and c-reactive protein dropped from 20.71 and she was discharged 8 days later. The complications of leiomyoma related to pregnancy include degeneration, abortion, preterm labor, placental abruption, and postpartum hemorrhage (2). Infection of leiomyoma, although extremely rare, is potentially life threatening. Among the 14 cases of pyomyoma reported since 1945, five occurred in postmenopausal women, and six were related to pregnancy or abortion (1). This may be due to vascular insufficiency in postmenopausal women or hemorrhage and necrosis during pregnancy. In this case, hemorrhage and leiomyoma necrosis may be the predisposing factors for the development of pyomyoma. Pyomyoma is more common in submucosal leiomyomas because their blood supply is relatively insufficient and their position adjacent to the uterine lumen predisposes them to ascending infection. The organisms causing pyomyoma are diverse, and include Gram-positive and Gram-negative bacteria (1); but pyomyoma caused by Candida has not been reported. Candida can be cultured from the vagina in 25% of women approaching term (3). It is possible that in this case pyomyoma was caused by Candida ascending from the vagina. The MRI of pyomyoma has not been reported. In this case, all leiomyomas displayed increased signal intensity at the margins on T1-weighted images. After contrast, the pyomyoma showed heterogeneous intensity and some enhancement besides irregular contour, which was compatible with inflammation. In conclusion, pyomyoma, although very rare, should be kept in mind in patients with leiomyomas. In patients with unexplained fever or abdominal pain, the possibility of pyomyoma should be considered. MRI is also helpful in making the diagnosis. Treatment consists of antibiotics and a hysterectomy.