{"paper_id":"76bdf3b2-8d90-4a1b-969e-7381f2886ffa","body_text":"Suppurative Leiomyoma (Pyomyoma) Mimicking Pyometra in a Postmenopausal Female: A Case Report Highlighting the Role of Adenomiosis and Chronic Salpingitis in Myometrial Abscess Formation.\nAuthors/Creators\nDescription\nABSTRACT\nBackground: Suppurative leiomyoma, also known as pyomyoma, is an extremely rare clinical entity\ncharacterized by suppuration, necrosis, and abscess formation within a uterine leiomyoma. In the post\nantibiotic era, this condition is rarely encountered and frequently misdiagnosed preoperatively as pyometra,\npelvic inflammatory disease, or uterine sarcoma.\nCase Presentation: A 50-year-old postmenopausal female (gravida 5, parity 1) presented with irregular\nvaginal bleeding, purulent discharge, and a significantly enlarged uterus. Preoperative clinical evaluations led\nto a diagnosis of uterine leiomyomas complicated by pyometra. An abdominal hysterectomy with bilateral\nsalpingectomy was performed. Gross pathological examination revealed multiple, well-demarcated, pus-filled\nencysted cavities (largest measuring 3.0 x 2.5 cm) embedded deeply within a hypertrophic miometrial wall,\nwhile the endometrial cavity remained empty and compressed, thereby excluding central pyometra.\nHistopathology confirmed acute suppurative endometritis-myometritis with multiple encysted myometrial\nabscesses (pyomyomas) arising in a background of diffuse myometrial hypertrophy, extensive adenomyosis,\nand bilateral acute-on-chronic suppurative salpingitis.\nConclusions: Pyomyoma should be considered in the differential diagnosis of postmenopausal women\npresenting with a pelvic mass, fever, or purulent discharge, especially when imaging suggests myometrial\ndegeneration. This case highlights how underlying extensive adenomyosis and chronic salpingitis can serve\nas structural and infectious conduits, facilitating direct bacterial extension into the myometrium to initiate\nlocalized pyogenic abscessuation.\nINTRODUCTION\nUterine leiomyomas represent the most common benign neoplasms of the female reproductive tract, affecting up to\n70-80% of women by the fifth decade of life. While these tumors frequently undergo various forms of aseptic\ndegeneration—such as hyaline, cystic, calcific, or red degeneration—suppurative degeneration, or the formation of\na pyomyoma, is an exceptionally rare complication. A pyomyoma occurs when a leiomyoma becomes infarcted,\nundergoes necrosis, and is subsequently seeded by pathogenic bacteria via hematogenous, lymphatic, or\nascending cervical routes.\nDue to its scarcity, clinicians rarely anticipate this diagnosis, and it is frequently misidentified as pyometra\n(accumulation of pus within the endometrial cavity), tubo-ovarian abscess, or a necrotic uterine sarcoma. This\ndiagnostic confusion is particularly pronounced in postmenopausal women, in whom diminished uterine vascularity\npredisposes leiomyomas to ischemic infarction and subsequent pyogenic colonization. Here, we present a clinicallyand pathologically peculiar case of a 50-year-old postmenopausal patient whose preoperative diagnosis of\npyometra was pathologically redefined as a localized suppurative endometritis-myometritis with encysted\npyomyomas, orchestrated by coexisting chronic salpingitis and extensive adenomyosis.\nCASE PRESENTATION\nA 50-year-old postmenopausal female (gravida 5, parity 1; LMP: menopausal) presented with a history of irregular,\nfrank vaginal bleeding, purulent vaginal discharge, pelvic discomfort, and a palpably enlarged uterus. Based on\nclinical findings and imaging indicating uterine enlargement and fluid collections, a presumptive diagnosis of a large\nleiomyomatous uterus complicated by pyometra was made. The patient underwent an elective total abdominal\nhysterectomy and bilateral salpingectomy. Operative findings reported large uterine fibroids associated with a\nsuspected pyometra.\nGross Pathological Findings\nThe specimen was received in a formalin-filled container, labeled \"uterus, both fallopian tubes,\" containing a total\nabdominal hysterectomy specimen with an attached right salpingectomy and a detached left salpingectomy. The\nuterus was brown, smooth, firm, and irregularly shaped, measuring 15.0 x 12.0 x 11.5 cm. Upon bisection, the cut\nsurface revealed multiple, well-demarcated, pus-filled cavities embedded directly within the thick myometrium; the\nlargest of these encysted abscesses measured 3.0 x 2.5 cm. Crucially, the endometrial cavity itself was empty,\nlined by light brown, thin tissue, measuring 4.0 x 3.0 cm, with a myometrial thickness of 3.0 cm. The cervical canal\nwas completely patent, containing no nabothian cysts or fluid accumulation. The bilateral fallopian tubes were\ndilated and rubbery; the right measured 6.0 x 1.4 x 1.0 cm, and the left measured 3.0 x 1.8 x 1.5 cm, with cut\nsurfaces revealing lumens filled with organizing, light-brown purulent tissue.\nFigure 1. Gross pathology of the bisectioned uterus\nA high-resolution photograph of the bisected uterus. The markedly hypertrophic and dark brown myometrium is seen. Most\nnotably, within the thickness of the myometrial wall, there are multiple well-circumscribed, 'encysted' abscess cavities filled with\nthick, creamy, light-brownish purulent material. The largest cavity measures approximately 3.0 cm in diameter and is surrounded\nby an intense rim of congested, red-brown inflammatory reaction, characteristic of a localized pyomyoma/myometrial abscess.\nAdjacent to the uterus, on the left, the dilated left fallopian tube (1.8x1.5 cm) filled with organizing purulent tissue (pyosalpinx) can be identified. Note that the endometrial cavity is compressed and empty of pus, definitively ruling out a central pyometra.\nMicroscopic Examination\nHistopathological evaluation of twelve duplicated slides confirmed a complex infectious and structural process. The\nendometrium demonstrated a weakly active proliferative pattern with overlapping peri-menopausal atrophic\nchanges, characterized by attenuated glands, reduced stromal cellularity, and focal cystic dilatation. Crucially, the\nunderlying myometrium demonstrated acute bacterial endometritis-myometritis. Within the myometrial wall, multiple\nencysted abscesses were identified, characterized by central pools of dense neutrophilic infiltrates, cellular debris,\nand necrosis, bordered by reactive stromal changes and granulation tissue.\nAdjacent myometrial sections demonstrated diffuse hypertrophy accompanied by extensive, deep adenomyosis,\nwhere benign endometrial glands and stroma were seen embedded within hypertrophic smooth muscle bundles.\nMultiple subserosal leiomyomas were noted, consisting of classic, benign interlacing fascicles of spindle-shaped\nsmooth muscle cells devoid of cytological atypia, necrosis, or atypical mitotic figures. The cervix exhibited chronic\nand active cervicitis with reactive epithelial changes and Nabothian cysts. Both fallopian tubes showed mild to\nmoderate acute suppurative salpingitis, marked by mucosal neutrophilic infiltration, reactive epithelial changes, and\nvascular congestion, while preserving the overall structure of the tubal wall.\nDISCUSSION\nA pyomyoma is a diagnostic enigma that typically presents with a triad of a palpable pelvic mass, pain, and fever,\naccompanied by leukocitosis. In postmenopausal women, the clinical picture is easily confused with a malignant\nprocess, such as leiomyosarcoma, or pyometra, particularly when vaginal discharge is present. In our case, the\nsurgical team expected a pyometra. However, gross and microscopic examination demonstrated that the\nendometrial cavity was empty, and the purulent collections were entirely \"encysted\" within the myometrium as\nlocalized abscesses.\nThis pathologically peculiar finding prompts an investigation into the route of infection. In patients with pyomyomas,\ninfection usually ascends from the cervix, or spreads hematogenously or lymphatically. We propose that in this\npatient, the infection ascended through the cervix, causing an acute but transient endometritis, and subsequently\nutilized two distinct \"conduits\" to penetrate deep into the uterine wall:\n1. Adenomyosis as an infectious conduit: The presence of extensive, diffuse adenomyosis provided pre\nexisting anatomical invaginations of endometrial glands and stroma deep into the hypertrophic myometrium.\nThese glands likely acted as a pathway, allowing the ascending bacterial pathogen to bypass the superficial\nendometrium and seed directly into the deep, hypertrophic myometrium.\n2. Bilateral acute-on-chronic salpingitis: The significant dilation and active purulent salpingitis suggest a\nconcurrent pelvic inflammatory process. The fallopian tubes, filled with organizing purulent debris, may have\nserved as a persistent reservoir of bacteria, contributing to the infection of the highly vascularized,\ndegenerating leiomyomas.\nThis case is highly educational because it emphasizes that a clinical presentation of pyometra with an enlarged\nuterus can mask a localized pyomyoma. Recognizing these distinct pathological entities is crucial, as their clinical\ncourses, risks of uterine rupture, and surgical complexities differ significantly. Pathologists and gynecologists must\nremain aware of this rare presentation to ensure comprehensive diagnosis and timely surgical intervention.\nCONCLUSIONS\nIn conclusion, suppurative leiomyoma (pyomyoma) remains a highly unusual, life-threatening complication in\nmodern gynecology. This case illustrates a unique pathological correlation where extensive uterine adenomyosis\nand chronic suppurative salpingitis acted as conduits for deep myometrial bacterial entry, culminating in multiple\nencysted myometrial abscesses. When managing postmenopausal patients with enlarged uteri, purulent discharge,\nand suspected pelvic infections, clinicians must maintain a high index of suspicion for pyomyoma, as early surgical\nintervention via hysterectomy remains the definitive, life-saving treatment.\nREFERENCES\n1. Karaman E, et al. Pyomyoma (suppurative leiomyoma) in a postmenopausal woman: a case report and review of the literature.\nJournal of Medical Case Reports. 2016;10:112.\n2. Schmid-Tannwald C, et al. Abscess formation in a uterine fibroid (pyomyoma) - a rare cause of acute abdomen: MRI findings.\nEuropean Journal of Radiology Extra. 2011;79(2):e27-e30.\n3. Gorny KR, et al. Pyomyoma after uterine artery embolization: a case report. Cardiovascular and Interventional Radiology. 2008;31(1): 210-213.\nFiles\nbe5581e4-df53-4657-9c25-e12c844a078a.jpg\nFiles\n(298.3 kB)\n| Name | Size | Download all |\n|---|---|---|\n|\nmd5:934beeca99b81ef70ab4913ebd04d50c\n|\n298.3 kB | Preview Download |","source_license":"CC0","license_restricted":false}