Not for Veterinarians Only: A Very Rare Case of Pyometra in an Elderly Female

Abstract

INTRODUCTION: Pyometra is a very rare but serious and potentially life threatening condition. It is defined as an accumulation of purulent material within the uterine cavity. It is a common presentation in the veterinary world however exceedingly rare in humans.CASE PRESENTATION: This is a 72-year-old female who presented to the emergency room with complaint of suprapubic abdominal pain and fullness. She reports having mild abdominal pain and fullness for 3 months however it progressively became worse over 2 weeks prior to presentation. She reported the pain to be very severe and sharp in nature. She denied any fever, chills, weight loss, dysuria, or vaginal discharge. In the ER CT of the abdomen and pelvis was obtained which revealed an intrauterine mass measuring 9.7x9.8x10.5 cm. Laboratory workup revealed leukocytosis with white blood cell count of 17.05x10^3. All other pertinent labs were within normal limits. She was transferred to our hospital and admitted to the medical floor. A pelvic ultrasound was then obtained which again revealed an enlarged uterus with a complex cystic appearing lesion. Ob/Gyn was consulted and she underwent a Pap smear and endometrial biopsy with culture. Pathology was negative for any malignancy however culture did grow streptococcus viridans. Patient was started on clindamycin and levofloxacin per infectious disease recommendations. She was then transferred to the intensive care unit as she became hypotensive and was then started on norepinephrine drip. Patient then underwent a dilatation and curettage which revealed copious amounts of purulent drainage in the uterus. Cultures again grew streptococcus viridans and she was continued on antibiotics. A repeat CT abdomen and pelvis was obtained which showed resolution of lesion. Patient remained in the ICU for monitoring and on postoperative day 4 went into cardiac arrest and subsequently deceased.DISCUSSION: Pyometra is reported to occur in 0.1-0.2% of all gynecologic patients [1]. The condition is commonly caused by malignant or benign tumors, radiation cervicitis, atrophic cervicitis or with the use of an intrauterine device. The classic triad of symptoms are vaginal discharge, postmenopausal bleeding and lower abdominal pain, however >50% of patients can be asymptomatic [2]. Pubmed literature review will reveal only a handful of such cases that have been reported. Most common microorganisms causing pyometra are E.coli and bactericides fragilis. A recent case report with literature review revealed a mortality rate of 22.2% [3]. Most suggest a CT scan and a pelvic ultrasound to obtain an accurate diagnosis and prompt initiation of antibiotics along with drainage of the pyometra. CONCLUSIONS: Pyometra is exceedingly rare however life threatening. This case illustrates the severity of the condition requiring prompt recognition and treatment.