AJR 2003; 181:1375-1377
© American Roentgen Ray Society
CT of a Ruptured Pyomyoma
Musturay Karcaaltincaba1,2 and
Gary S. Sudakoff3
1 Department of Radiology, Digital Imaging Section, Medical College of
Wisconsin, Milwaukee, WI 53226.
2 Present address: Department of Radiology, Hacettepe University, Ankara 06100,
Turkey.
3 Department of Radiology, Medical College of Wisconsin, Froedtert Memorial
Lutheran Hospital, 9200 W Wisconsin Ave., Milwaukee, WI 53226.
Received February 19, 2003;
accepted after revision April 7, 2003.
Address correspondence to G. S. Sudakoff
(gsudakof{at}mcw.edu).
Introduction
Pyomyoma, or suppurative leiomyoma, is a rare and potentially fatal
complication of uterine leiomyomas. Most cases occur as complications of
pregnancy, but cases also occur idiopathically in postmenopausal women. The
diagnosis of pyomyoma is difficult because of its insidious presentation and
lack of reported imaging and clinical localizing findings. In this case
report, we describe the CT findings of a ruptured pyomyoma, presumably caused
by the spontaneous abortion of a fetus at 17 weeks' gestation. To our
knowledge, ours is the first report on the CT findings of a ruptured pyomyoma
in the radiologic literature.
Case Report
A 36-year-old woman, gravida 2, para 0, presented to our emergency medicine
department with acute onset of vaginal bleeding and pelvic pain. A serum
pregnancy (ß-human chorionic gonadotropin) test returned a positive value
of 236 mIU/mL. By menstrual dating, we determined the gestation was
approximately in its 17th week. Pelvic sonography revealed a deformed
nonviable fetus, little or no amniotic fluid, a myomatous uterus, and the
absence of free pelvic fluid (Figs.
1A and
1B). After several hours, the
patient completed a spontaneous abortion and did not require obstetric
intervention. The patient was discharged the same day in stable condition. She
returned 7 days later with acute abdominal pain and fever of 39.4°C.
Physical examination revealed diffuse abdominal tenderness with rebound. WBC
of 27,000/µL, serum ß-HCG levels, and urinalysis results were normal.
Pelvic sonography revealed a normal endometrium and no retained products of
conception. Numerous uterine leiomyomas were again identified and included
interval enlargement of a right subserosal leiomyoma that developed internal
echogenic debris and reverberation artifact. A small amount of free fluid was
also identified in the cul-de-sac (Fig.
1C).
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Fig. 1A. —36-year-old woman who presented with acute abdomen 7 days
after spontaneous abortion. Initial longitudinal sonogram of lower uterine
segment (straight arrows) obtained during spontaneous abortion shows
deformed fetal head (curved arrows) and lack of placenta and amniotic
fluid.
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Fig. 1B. —36-year-old woman who presented with acute abdomen 7 days
after spontaneous abortion. Transverse sonogram obtained through uterine
fundus at same time as A shows dominant right lateral uterine leiomyoma
(arrows).
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Fig. 1C. —36-year-old woman who presented with acute abdomen 7 days
after spontaneous abortion. Transverse sonogram obtained 7 days after
spontaneous abortion shows right lateral uterine mass with interval
development of internal echoes and reverberation artifact (arrow),
suggestive of pyomyoma.
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Contrast-enhanced CT confirmed the presence of gas and debris in a right
subserosal uterine leiomyoma with intraperitoneal air and fluid
(Fig. 1D). Multiplanar sagittal
and coronal reformatted images were obtained by reconstructing
5.0-mm-collimated images at 3-mm intervals. Reformatted images showed
irregularity and probable disruption of the wall of the pyomyoma that were not
visible on axial images. Intraperitoneal gas and fluid were also more clearly
shown on reformatted images than on routine axial images (Figs.
1E and
1F).
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Fig. 1D. —36-year-old woman who presented with acute abdomen 7 days
after spontaneous abortion. Axial 5.0-mm-collimated CT scan of lower abdomen
shows several uterine leiomyomas. Dominant right lateral leiomyoma contains
internal gas and debris (arrows) and small amount of surrounding
fluid. Wall of pyomyoma appears intact.
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Fig. 1E. —36-year-old woman who presented with acute abdomen 7 days
after spontaneous abortion. Coronal CT reformation shows enlarged uterus (U)
with irregularity of superior wall of right lateral pyomyoma (arrow),
suggesting focal disruption.
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Fig. 1F. —36-year-old woman who presented with acute abdomen 7 days
after spontaneous abortion. Sagittal CT reformation obtained on right side
through pyomyoma shows irregularity of superior wall (curved arrows)
suggesting sites of focal disruption with surrounding intraperitoneal fluid
and air (straight arrows).
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Laparotomy revealed a large right lateral subserosal uterine leiomyoma that
was leaking purulent material directly into the peritoneal cavity. An extended
myomectomy was performed and included two adjacent uterine myomas. The
peritoneal cavity was copiously irrigated, and the patient had an uneventful
postoperative course. Culture of the peritoneal fluid was positive for
Peptostreptococcus tetradrus. Histopathologic examination of the
excised specimen showed extensive necrosis and hyaline degeneration with
peripheral inflammatory changes. No evidence of malignancy was identified.
Discussion
Uterine pyomyomas are rare, with fewer than 100 cases reported in the
literature
[1–6].
Only 16 cases have been reported since 1945
[1,
2]. Most reported cases
occurred before the clinical use of IV antibiotics. Pyomyomas have been
associated with the following clinical conditions: postpartum, after either
vaginal or cesarean delivery; myomatous uterus; ascending uterine infections;
and cervical stenosis. Pyomyomas that develop in postmenopausal women are
presumably caused by ischemia resulting from hypertension, diabetes, or
atherosclerosis [2]. Three
different routes of infection may lead to the development of pyomyoma:
contiguous spread from the endometrial cavity, direct extension from adjacent
bowel or adnexa, and hematogenous or lymphatic spread from infection elsewhere
in the body [1,
2]. Pyomyomas develop slowly
over days or weeks, particularly in patients after delivery or abortion, and
clinical diagnosis is often difficult. Pyomyoma may appear as single or
multiple tumors and may extend deep in the myometrium; they may rupture or
penetrate into the abdominal cavity, adjacent pelvic structures, abdominal
wall, or endometrial cavity. The definitive treatment for pyomyoma is
hysterectomy or myomectomy and aggressive antibiotic therapy
[3,
4].
Uterine leiomyomas are the most common neoplasm of the uterus
[7,
8]. CT findings of uterine
leiomyomas show uterine enlargement and contour deformity
[7]. They usually show a
uniformly solid density, but necrosis may occur because of hyaline
degeneration [7]. Calcification
is common and is the most specific sign of uterine leiomyomas
[7,
8]. Uterine leiomyomas are
estrogen-dependent, and up to 50% may increase in size during pregnancy
[8].
To our knowledge, CT findings of a ruptured pyomyoma with peritonitis have
not been described. Earlier case reports have mentioned only nonspecific
sonographic findings, which are not diagnostic
[3–5].
A single case report by Genta et al.
[1] described the CT appearance
of a large multicystic mass extending from the pelvis that was thought to be
an ovarian carcinoma. In our patient, CT with sagittal and coronal
reformations allowed preoperative diagnosis of a ruptured pyomyoma that
consisted of gas and debris in the leiomyoma, discontinuity of leiomyoma wall,
and intraperitoneal free gas and fluid.
The echogenic foci seen sonographically in the enlarging leiomyoma in our
patient suggested the presence of gas but was not conclusive. Published
reports describe sonographic findings in pyomyoma that include an enlarging
pelvic mass or a heterogeneous pelvic mass with solid and cystic components
[5]. One report mentions the
development of increased echogenicity in a leiomyoma during pyomyoma formation
[4], but no prior report
mentions gas in a pyomyoma showing reverberation artifact.
Treatment of uterine pyomyoma consists of IV antibiotics and myomectomy or
hysterectomy. Less extensive myomectomy may be performed depending on the size
and number of pyomyomas and desire for future conception. Early diagnosis of
uterine pyomyoma is critical because mortality rates approach 21–30%
[1].
Enlargement of a uterine leiomyoma during pregnancy is common and is not
indicative of developing pyomyoma. The presence of gas in a uterine leiomyoma,
as seen in this patient, is diagnostic for pyomyoma. Intraperitoneal air and
fluid associated with pyomyoma are diagnostic for peritonitis and suggest a
pyomyoma rupture. Contrast-enhanced CT with sagittal and coronal reformations
allows accurate diagnosis of pyomyoma and pyomyoma rupture by improving
visualization of the wall discontinuity and the intraperitoneal air and
fluid.
References
- Genta PR, Dias ML, Janiszewski TA, Carvalho JP, Arai MH, Meireles
LP. Streptococcus agalactiae endocarditis and giant pyomyoma
simulating ovarian cancer. South Med J2001; 94:508
–511[Medline]
- 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 Surv1990; 45:563
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- Gupta B, Sehgal A, Kaur R, Malhotra S. Pyomyoma: a case report.
Aust N Z J Obstet Gynaecol1999; 39:520
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- Grune B, Zikulnig E, Gembruch U. Sepsis in second trimester of
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- Tobias DH, Koenigsberg M, Kogan M, Edelman M, LevGur M. Pyomyoma
after uterine instrumentation: a case report. J Reprod
Med 1996;41:375
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section. Acta Obstet Gynecol Scand2002; 81:571
–572[Medline]
- Casillas J, Joseph RC, Guerra JJ Jr. CT appearance of uterine
leiomyomas. RadioGraphics1990; 10:999
–1007[Abstract]
- Salem S. The uterus and adnexa. In: Rumack CM, Wilson SR,
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Introduction
Case Report
