Spontaneous Ruptured Pyomyoma in a Nulligravida Female
Senthil Kumar Aiyappan,
Professor and Head, Department of Radiodiagnosis, SRM Medical College Hospital and Research Centre, SRMIST, Kattankulathur, Chengalpattu-603203, Tamil Nadu, India.
A 41-year-old unmarried nulligravida female presented with complaints of dysuria and intermittent fever for one week. There was no history of menstrual symptoms, uterine instrumentation, or uterine artery embolisation. The patient was a known case of type 2 diabetes and was on insulin treatment. There was no history of hypertension, bronchial asthma, tuberculosis, or thyroid disorder. On examination, the patient had a fever (99.8o F) and stable vital signs. Abdominal examination revealed a uterus size equivalent to 16 weeks of pregnancy. Blood investigations showed leukocytosis with a predominance of neutrophils (Total White Blood cells (WBC) count: 22,370 cells/cu mm with 83% neutrophils) and an elevated Erythrocyte Sedimentation Rate (ESR) of 96 mm/hr. HbA1c was 12.1%, indicating uncontrolled diabetes with an estimated average blood sugar level of 301 mg/dL. A pap smear was negative for intraepithelial lesion or malignant cells. Abdominal ultrasound revealed an enlarged uterus measuring 11.5×9.3×7.9 cm with an anterior wall fibroid measuring approximately 8.3×8.4 cm in the fundal region (Table/Fig 1)a,b. Abdominal and pelvic MRI showed a large heterogeneous lesion with cystic areas measuring 9.0×9.2×8.8 cm in the right antero-lateral myometrial wall (Table/Fig 2)a-d.
Based on the ultrasound and Magnetic Resonance Imaging (MRI) findings, the possibility of a large anterior wall subserous fibroid with cystic degeneration was considered. The patient underwent surgery, revealing an infected degenerated fibroid in the anterior wall of the uterus with pus drainage, indicating rupture. Foul-smelling pus of approximately 250-300 mL was drained from the peritoneal cavity. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. An intraperitoneal drain was placed, and the skin was closed with 2-0 ethilon. No intraoperative or post-operative complications occurred, and the specimen was sent for histopathological analysis (Table/Fig 3)a,b. Histopathology revealed a leiomyomatous uterus with degenerative changes. Culture and sensitivity analysis of the pus showed occasional pus cells, but no organisms were observed.