Images in clinical medicine. Pneumoperitoneum due to spontaneously perforated pyometra

n engl j med 354;21 www.nejm.org may 25, 2006 e23 A 40-year-old woman with long-standing diabetes presented to the emergency room with fever (temperature, 39.5°C) and diffuse abdominal pain. On admission, she had a distended abdomen with muscular rigidity, Blumberg’s sign, a white-cell count of 23,530 per cubic millimeter, and a C-reactive protein level of 27.5 mg per deciliter. A chest roentgenogram, obtained while the patient was erect, showed bilateral subphrenic free air (Panel A, arrowheads). Computed tomography showed a large abscess (11 cm) containing air (Panel B, arrowhead) in the lower abdomen. At laparotomy, a perforated necrotic area on the uterine fundus (Panel C, arrowhead) and infected ascites were noted. The patient was treated with subtotal hysterectomy and drainage and had an uneventful recovery.