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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 101-103

Total laparoscopic hysterectomy of an endocervical pyomyoma over previous cesarean section wound


1 Department of Obstetrics and Gynecology, Buddhachinnaraj Hospital, Phitsanulok, Thailand; Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
2 Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital; Chang Gung University College of Medicine, Taoyuan, Taiwan
3 Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Keelung, Taiwan

Date of Submission23-Oct-2018
Date of Decision20-Sep-2019
Date of Acceptance18-Mar-2020
Date of Web Publication28-Apr-2020

Correspondence Address:
Dr. Kuan- Gen Huang
Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, No. 5, Fuxing Street, Kweishan, Taoyuan 333
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/GMIT.GMIT_103_18

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  Abstract 


A 41-year-old female, G2P2, who experienced menorrhagia for 1 month, had had a history of myoma uteri for the previous 5 years. The computed tomography showed a leiomyoma mass of approximately 8 cm. She underwent a total laparoscopic hysterectomy with bilateral salpingectomy. This pyomyoma originated in the endocervix over the cesarean section wound. The postoperative care was uneventful. Pyomyoma is a rare condition and is even rarer in premenopausal patients without a history of pregnancy or uterine instrumentation. The spontaneous pyomyoma at the endocervical leiomyoma demonstrated an unusual case in the absence of risk factors. Pyomyoma could be considered as a diagnosis in patients without fever, history of fibroids, and no other identifiable sources of infection.

Keywords: Endocervix myoma, laparoscopy, pyomyoma


How to cite this article:
Wasinghon P, Huang KG, Lai SY. Total laparoscopic hysterectomy of an endocervical pyomyoma over previous cesarean section wound. Gynecol Minim Invasive Ther 2020;9:101-3

How to cite this URL:
Wasinghon P, Huang KG, Lai SY. Total laparoscopic hysterectomy of an endocervical pyomyoma over previous cesarean section wound. Gynecol Minim Invasive Ther [serial online] 2020 [cited 2020 Sep 29];9:101-3. Available from: http://www.e-gmit.com/text.asp?2020/9/2/101/283331




  Introduction Top


Pyomyoma has been reported since 1945 with some fatalities and an association with either pregnancy or postmenopausal patients who have underlying vascular disease.[1] Pyomyoma is a suppurative leiomyoma, which is a rare complication resulting from the bacterial colonization of an infarcted or ischemic leiomyoma, but life-threatening. The incidence of pyomyoma has decreased due to the development of antibiotics.[2] Pyomyoma occurs most commonly during the premenopausal period, postmenopausal status, pregnancy or the immediate postpartum period, as well as arises after uterine instrumentation, after uterine artery embolization (UAE), or in immunocompromised patients. The mode of infection could be ascending, which the most likely cause of pyomyoma is direct infection of bacteria in a vascular compromise, hematogenous, or lymphatic spread.[1],[2],[3],[4],[5],[6],[7] As pyomyoma is a rare condition, therefore the diagnosis is difficult. This case presented some uncertain symptoms and was difficult to identify from the imaging. The definitive diagnosis was only possible with surgery. The patient was diagnosed with endocervical pyomyoma over the previous cesarean section wound, in which this diagnosis was distinguished from previous reports.


  Case Report Top


A 41-year-old female, G2P2 with the two previous cesarean sections, had been noted with a leiomyoma for 5 years. She had performed hysteroscopic polypectomy in the previous 3 years due to progressive dysmenorrhea and menorrhagia at the Obstetrics and Gynaecology Department of the Chang Gung Memorial Hospital, Taoyuan, Taiwan. She had repeated the second episode of menorrhagia for 1 month, and the pelvic examination showed cervical erosion with leukorrhea, a 14-week size enlargement of the uterus with tenderness. The body mass index was 18.6 kg/m2, vital signs were normal, and there was no fever. The hemoglobin levels were 8.7 g/dl, the white blood cell count was 8900/μl, and the CA-125 level was 121 U/ml. The computed tomography (CT) scan showed a large lobulated heterogeneous tumor approximately 8.5 cm × 6.9 cm × 6.4 cm with necrotic change at the lower part of the uterus and cervical portion involving the whole layer of the anterior uterine wall. The tumor was anteriorly protruding and closely attached to the superior wall of the urinary bladder. The patient underwent surgery with a total laparoscopic hysterectomy (TLH) and bilateral salpingectomy (BS). After the Veress needle was inserted to establish the pneumoperitoneum, the 10-mm cannula was placed in at the umbilicus. The two 5-mm cannulas were inserted above the anterior superior iliac spine for 2 cm bilaterally. The one 5-mm cannula was inserted above the left lower cannula about 8 cm, parallel to the umbilicus cannula. During laparoscopic surgery, the uterus had a normal surface. The tumor mass was located at the lower segment of the uterus, which was over the previous cesarean section wound [Figure 1]. The removed specimen was dissected that showed the pus was loculated at the endocervical myoma; the 7.5 cm endocervical myoma was located at the previous cesarean section scar. The pus content was extruded from the endocervical myoma, and the specimen was sent for frozen section intraoperatively. The frozen section revealed acute and chronic inflammation. The histopathology revealed a degenerative endocervical leiomyoma with inflammation. The postoperative care was uneventful. The patient consent form has been obtained. The study was approved by the Ethics Committee of the Chang Gung Memorial Hospital (Registration Number 20200038444B0).
Figure 1: The gross specimen showed the pyomyoma of the uterine cervix approximately 8 cm

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  Discussion Top


A pyomyoma patient without infectious symptoms had menorrhagia. As discussed in 1990 by Greenspoon et al., pyomyoma was reported from 1871 to 1945 with 75 cases by Miller, and 11 cases from 1945 to 1988 by Kelly and Cullen. From the unspecific symptoms, it would seem difficult to diagnose pyomyoma; however, the mortality rate is approximately 30%.[1] The predisposing factors for pyomyoma have noted a history of uterine leiomyoma, pregnancy, abortion, menopause, UAE, intrauterine device, cervical stenosis, vascular insufficiency (diabetes, hypertension, and atherosclerosis), and systemic disease or infection. Three routes of infection can produce a pyomyoma including direct spreading from the endometrial cavity, the extension of infection from adjacent organs, and hematogenous or lymphatic spreading from occult or apparent infection.[1],[2],[3],[4],[5],[6],[7] The presented symptoms were fever,[1],[6],[7] amenorrhea,[2] abdominal pain,[3],[6] menometrorrhagia,[4] hypermenorrhea with severe dysmenorrhea,[5] and palpated abdominal mass.[7] This case had experienced menorrhagia for 1 month. Previous reports showed the varied size of the uterine mass between 7 and 50 cm [Table 1]. Greenspoon et al. had reported that the patient was dead due to septic shock.[1] Myomectomy could preserve fertility in nulliparous women[3],[6] which Pinton et al. showed the patient became pregnant 2 years later after having a myomectomy.[6] Obele et al. showed that on postprocedure day 14 of the uterine fibroid embolization, the patient had a pyomyoma then a supracervical hysterectomy with BS was conducted.[4] The blood culture revealed Staphylococcusaureus, Enterococcus,Actinomycesmeyeri, and  Escherichia More Detailscoli.[1],[2],[5],[7] There was a high level of CA 125 in the gynecologic oncology and nongynecologic oncology that the previous report showed 200 U/ml, 2 whereas the level of CA 125 was 121 U/ml in this patient. The CT findings of the uterine leiomyomas showed uterine enlargement and solid density, but the pyomyoma had nonspecific findings.[8] The idiopathic pyomyoma mostly occurred in degenerative or necrotic tissue leiomyoma incidentally.[1],[2],[3],[4],[5],[6],[7],[8] Thus, gynecologists must be aware of the possibility of pyomyoma when presented with an abdominal tumor. Pyomyoma is a life-threatening medical condition that can result in death.[1] This case presented menorrhagia with leiomyoma without an obvious source of infection. As the surgery was the only definitive diagnosis and treatment, this patient had a fibroid without pyrexia, which could be difficult to diagnose. Therefore, the diagnosis was an endocervical pyomyoma over the previous cesarean section wound; consequently, the operation was a TLH with BS. In general, the leiomyoma was located at various sites such as subserous, intramural, or submucous myoma.[9],[10],[11] However, this case is an unusual diagnosis of pyomyoma. The pyomyoma was located at the lower segment of the uterus, which was a different site than previous reports as shown in [Table 1]. This case can guide the gynecologist to the concern of diagnostic.
Table 1: The review of pyomyoma cases

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors appreciate the Asia-Pacific Association for Gynecologic Endoscopy and Minimally Invasive Therapy for providing the International Fellowship Endoscopy Training Program at Chang Gung Memorial Hospital for Dr. Phornsawan Wasinghon. The study was approved by the Ethics Committee of the Chang Gung Memorial Hospital (Registration Number 202000384B0).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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 Surv 1990;45:563-9.  Back to cited text no. 1
    
2.
Iwahashi N, Mabuchi Y, Shiro M, Yagi S, Minami S, Ino K. Large uterine pyomyoma in a perimenopausal female: A case report and review of 50 reported cases in the literature. Mol Clin Oncol 2016;5:527-31.  Back to cited text no. 2
    
3.
Read S, Mullins J. Spontaneous Ruptured Pyomyoma in a Nulligravid Female: A Case Report and Review of the Literature. Case Rep Obstet Gynecol [Internet] 2018. doi:10.1155/2018/1026287. Available from: https://www.hindawi.com/journals/criog/2018/1026287/. [Last accessed on 2018 Dec 01].  Back to cited text no. 3
    
4.
Obele CC, Dunham S, Bennett G, Pagan J, Sung LY, Charles HW. A Case of Pyomyoma following Uterine Fibroid Embolization and a Review of the Literature. Case Rep Obstet Gynecol [Internet] 2015. doi:10.1155/2016/9835412. Available from: https://www.hindawi.com/journals/criog/2016/9835412/. [Last accessed on 2018 Dec 01].  Back to cited text no. 4
    
5.
Chen ZH, Tsai HD, Sun MJ. Pyomyoma: A rare and life-threatening complication of uterine leiomyoma. Taiwan J Obstet Gynecol 2010;49:351-6.  Back to cited text no. 5
    
6.
Pinton A, Aubry G, Thoma V, Nisand I, Akladios CY. Pyomyoma after abortion: Uterus conserving surgery is possible to maintain fertility. Case report. Int J Surg Case Rep 2016;24:179-81.  Back to cited text no. 6
    
7.
Gupta B, Sehgal A, Kaur R, Malhotra S. Pyomyoma: A case report. Aust NZ J Obstet Gynaecol 1999;39:520-1.  Back to cited text no. 7
    
8.
Karcaaltincaba M, Sudakoff GS. CT of a ruptured pyomyoma. AJR Am J Roentgenol 2003;181:1375-7.  Back to cited text no. 8
    
9.
Yang W, Luo N, Ma L, Dai H, Cheng Z. The changes of surgical treatment for symptomatic uterine myomas in the past 15 years. Gynecol Minim Invasive Ther 2018;7:10-5.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Chen L, Sun W, Chen H, Fei X. A benign uterine leiomyoma with disturbing appearance. Gynecol Minim Invasive Ther 2019;8:44-5.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Otake A, Horai M, Tanaka E, Toda A, Miyoshi Y, Funada R, et al. Influences of total laparoscopic hysterectomy according to body mass index (underweight, normal weight, overweight, or obese). Gynecol Minim Invasive Ther 2019;8:19-24.  Back to cited text no. 11
[PUBMED]  [Full text]  


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