A Case of Pyomyoma following Uterine Fibroid Embolization and a Review of the Literature

Prolapse of a Large Degenerating Uterine Leiomyoma: A Case Report

Uterine leiomyomas (ULs) are common benign tumors seen in a large percent of women that can be classified based on their location within the uterus. They can cause a number of pelvic complications and can be managed medically, but more often surgically. Uterine pyomyomas often occur postpartum, possibly from infarction, and can lead to degeneration and sepsis. Our patient presents with a two-month development of a potential pyomyoma, found initially on computed tomography (CT). Office exam reveals a protruding mass from the cervical os, and removal was attempted but ultimately postponed for general anesthesia exam due to pain. The leiomyoma was removed and shown to be necrosing. Pyomyomas are often insidious and can often mimic other concerning pathologies. Modern imaging can show lesions within the pelvis but struggle to determine between fluid collection and possible infarcted masses. The importance of quality care measures in cases like this deserve to be emphasized to prevent serious complications.

Uterus-preserving management of pyomyoma: Case report of a rare complication after uterine artery embolization

Background

Pyomyoma of the uterus is a rare but severe complication of uterine artery embolization (UAE). This report describes the uterus-preserving management of a case of fast-developing pyomyoma. Screening methods to minimize the risk of this condition are discussed.

Case

A 46-year-old woman presented with fever, abdominal pain and blood stream infection on the third day after UAE, which had been performed to treat symptomatic uterine myomatosus. Broad-spectrum antibiotics proved inadequate. Magnetic resonance imaging (MRI) showed a possible superinfection of the necrotic myoma. Vaginal smear showed the same organism, a resistant Escherichia coli, as in the blood culture. Because the patient declined hysterectomy, multiple hysteroscopies with removal of necrotic pyomyoma were performed. In addition, an intrauterine gentamicin chain was placed. To our knowledge, this is the first case of pyomyoma immediately after UAE and the first report of successful hysteroscopic treatment in a septic patient.

Conclusion

In order to reduce the risk of pyomyoma, pre- and postinterventional algorithms should be used.

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Initial symptoms of pyomyoma can easily be confounded with post embolization syndrome after UAE.

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Localized gas collection of a necrotic myoma combined with signs of infection can be an indication for pyomyoma.

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Hysteroscopical resection is an alternative to abdominal surgery e.g. in case of high operative risk/wish of childbreading.

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Patients with germ detection in vaginal smear should be considered high risk patients for developing a pyomyoma after UAE.

Ruptured pyomyoma - Rare complication of post-uterine artery embolization: A case report

Leiomyomas, also termed as fibroids, are benign smooth, muscle neoplasms seen in 70–80% of women by the age of 50 years. Uterine artery embolization (UAE) is a minimally invasive procedure that involves cessation of vascular supply to the fibroids, by infusion of gelatinous microspheres into the uterine arteries. Pyomyoma is a suppurative leiomyoma, secondary to infection of necrotic tissue. It is an infrequent complication of uterine artery embolization (UAE). Pyomyoma can lead to sepsis, peritonitis, and respiratory distress syndrome resulting in high morbidity and mortality. Due to its rarity, high suspicion is crucial in the diagnosis, and prompt treatment is recommended to reduce mortality. Ultrasound, computed tomography, and magnetic resonance imaging assist in diagnosis. We present a case of a 44-year-old woman with ruptured pyomyoma, following an UAE intervention. The patient was treated with total abdominal hysterectomy and salpingo-oophorectomy along with peritoneal irrigation and drainage.

Value of diffusion-weighted magnetic resonance imaging in the diagnosis of pyomyoma

Pyomyomas are rare lesions that develop from the suppurative degeneration of ischemic leiomyomas. Pyomyomas can lead to sepsis, so early diagnosis is crucial. Due to their rarity and often nonspecific findings on ultrasonography and computed tomography diagnosis is often delayed. We present a case of a woman who presented with abdominal pain and fever. The computed tomography showed a large hypodense uterine lesion with slight peripheral enhancement without gas in the lesion. The diffusion-weighted magnetic resonance imaging showed restricted diffusion, demonstrating the presence of pus and confirming the diagnosis of pyomyoma. Diffusion-weighted imaging should be done in cases of suspected pyomyomas when computed tomography findings are nonspecific.

Surgical and Radiological Management of Complicated Uterine Leiomyoma Aided by 3D Models in a Patient with Fibrodysplasia Ossificans Progressiva

Patient: Female, 27-year-old

Final Diagnosis: Fibrodysplasia ossificans progressiva

Symptoms: Fever

Medication: —

Clinical Procedure: —

Specialty: Endocrinology and Metabolic • Obstetrics and Gynecology

Can uterine artery embolization be an alternative to plastic and reconstructive uterus operation by minimally invasive surgery?

Introduction: Plastic and reconstructive minimally invasive surgery has been established as gold standard in myomectomy. Therapy failure eventually leads to future surgical interventions or hysterectomy: surgeons and patients should be aware of the risks and benefits. We conducted a systematic review to analyse the evidence on the therapeutic indications and adverse events associated with uterine artery embolization and thereby evaluating if this method could be a valid alternative therapy. Methods: In concordance with PRISMA guidelines, literature research was made in PubMed, Cochrane Library, UpToDate, Amboss and Medline databases. Clinical trials, reviews and case reports published in English between January 2010 and June 2020 were included. Results: 44 articles were included out of 838 papers identified at initial search. Regarding uterine fibroids, three original papers and one Cochrane review reported the benefits of the procedure as an alternative to surgery, even in large and giant fibroids. Furthermore, several studies discussed the use of embolization for postpartum haemorrhage to decrease rates of hysterectomy after other haemostatic methods were exhausted, because of the potential risk of abnormal placentation in a future pregnancy. The procedure can also be successfully used as prophylactic method in different obstetrical procedures. Conclusions: The use of embolization in different uterine pathologies is a minimally invasive procedure as an alternative to surgery, especially in women who desire to preserve their uterus. Its related complications are described and can be avoided by a stringent indication of the procedure. More evidence regarding fertility after UAE, use of the procedure prophylactically in obstetrical haemorrhage or in adenomyosis is needed.

Total Laparoscopic Hysterectomy of an Endocervical Pyomyoma Over Previous Cesarean Section Wound

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.

Pyomyoma after uterine artery embolization: A case report

Background

Uterine pyomyoma is a rare complication of uterine artery embolization (UAE), and causes significant morbidity and mortality. This report describes the diagnosis and prompt management of this condition.

Case

A 48-year-old woman presented with fever, chills, and diffuse abdominal pain 15 days after undergoing UAE for symptomatic fibroids. Computed tomography showed the uterus to be significantly distended, with multiple intra-cavitary masses containing a large amount of gas and air–fluid level. Sepsis secondary to post-UAE pyomyoma was suspected. Hemodynamic resuscitation and broad-spectrum antibiotics were immediately started. The patient underwent emergency exploratory laparotomy with total hysterectomy.

Conclusion

In order to ensure appropriate and timely intervention, the diagnosis of uterine pyomyoma should be considered in patients presenting with signs of infection and abdominal pain after UAE.

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Uterine pyomyoma is a potentially life-threatening complication of uterine artery embolization.

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It is important to have a high index of suspicion among first line providers for uterine pyomyoma when patients present with the triad of fever, leiomyoma, and no other source for infection.

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A timely management of pyomoyma consists of appropriate resuscitation and antibiotics in addition to surgery when clinically warranted.

Uterine-sparing management of pyomyoma after uterine fibroid embolization

Uterine fibroid embolization (UFE) is an increasingly popular treatment for uterine fibroids. One extremely rare complication after fibroid embolization is pyomyoma, which is the localized infection of the leiomyoma after embolization. Only 10 cases of pyomyoma after UFE have been reported in the literature. We present a case of delayed submucosal pyomyoma identified on computed tomography after 42 days post-UFE. While the majority of previously reported cases were managed by hysterectomy, our patient was treated with a uterine-sparing hysteroscopic transcervical approach. A high level of clinical suspicion is necessary to diagnose this complication after UFE to avoid major morbidity. Submucosal pyomyomas offer a favorable anatomical location easily accessible by hysteroscopy and a conservative approach may be sufficient to manage this complication.

Successful pregnancy after uterine artery embolization for uterine arterovenous malformation: a rare case report

Objective

This paper reports on a rare case of pregnancy after uterine artery embolization (UAE) for uterine arteriovenous malformation (AVM). Debate exists about persistence of fertility in women after UAE. Adverse effects of this technique can modify both uterine echostructure, inducing necrosis and infarction, endometrial atrophy and uterine artery rupture, and ovarian reserve, causing persistent amenorrhea. Ovarian reserve appears to be affected by UAE in pre-menopausal women. However, younger ovaries (according to biological ovarian age) exhibit a greater capacity for recovery after ovarian damage. Therefore, larger studies are needed for more conclusive results.

Case report

A 28-year-old woman was admitted to our department due to life-threatening uterine bleeding, resulting in tachycardia, pallor, and sweating. The patient came with a history of two spontaneous miscarriages. After sonography and computed tomography, AVMs were identified at uterine fundus and anterior wall.

Conclusion

The pathogenesis of infertility after UAE is not yet known. The peculiarity of this case was that, only few months later, the patient became pregnant and gave birth to a live fetus at 37 weeks with cesarean delivery.

Spontaneous Ruptured Pyomyoma in a Nulligravid Female: A Case Report and Review of the Literature

Introduction

Pyomyoma, or suppurative leiomyoma, is a rare complication of uterine fibroids. It occurs most commonly in the setting of pregnancy, the immediate postpartum period, or postmenopausal status. It may also arise after recent uterine instrumentation, after uterine artery embolization, or in immunocompromised patients. The most likely cause of pyomyoma is vascular compromise followed by bacterial seeding from direct, hematogenous, or lymphatic spread. Diagnosis is difficult, as the condition is rare, presents with vague symptoms, and is difficult to identify on imaging. Definitive diagnosis is only possible with surgery. Pathology shows a degenerating fibroid with hemorrhage, necrosis, cystic degeneration, and/or inflammatory change. Cultures of the pus contained within often show polymicrobial infection.

Case Presentation

Our patient is a 24-year-old nulligravid female who presented with a surgical abdomen, fever, hypotension, and leukocytosis. She had no significant prior medical or surgical history, no history of uterine instrumentation, and no history of pelvic infection; she was not currently sexually active at the time of presentation. She was taken to the operating room, where she underwent diagnostic laparoscopy. This showed a ruptured pyomyoma originating in the left broad ligament. She then underwent laparoscopic myomectomy. She was transferred to the ICU intubated; she slowly recovered on IV antibiotics and was discharged home on postoperative day 10.

Discussion

Pyomyoma is a rare condition and is even rarer in premenopausal patients without recent history of pregnancy or uterine instrumentation. This demonstrates an unusual case of spontaneous pyomyoma in the absence of risk factors, other than a history of known fibroids. Pyomyoma should be considered as a diagnosis in patients with sepsis, history of fibroids, and no other identifiable source of infection.

Uterine fibroid therapy using interventional radiology mini-invasive treatments: current perspective

Uterine fibroids are common benign tumors of unclear etiopathology that affect the female reproductive tract. They are responsible for considerable morbidity and deterioration of life quality, and may have a negative impact on the reproductive system as well. Besides surgery aided by uterus-saving techniques, several minimally invasive procedures are now available within the field of interventional radiology that represent a valid solution for women who desire pregnancy and relief from disease-specific symptomatology. The main advantages offered by these techniques are low grade of invasiveness and short times of hospitalization. The most diffuse techniques are uterine artery embolization (UAE) and magnetic resonance-guided high-intensity focused ultrasound (MRgFUS). UAE is an endovascular procedure whose goal is obtained by provoking ischemia of the uterine vessels. MRgFUS is a thermoablation procedure that selectively ablates the symptomatic fibroids. In this review study, both procedures will be described, including a description of technical details, indications, contraindications, complications, and outcomes.