Peer Reviewed

Photoclinic

Pyometra

Volume 58 - Issue 12 - December 2018

Authors:
James D. Denham, MS*
University of South Florida Morsani College of Medicine, Tampa, Florida

Raj Patel*
University of South Florida, Tampa, Florida

Jesus Diaz Vera
University of South Florida Morsani College of Medicine, Tampa, Florida

Jing-Yi Jeannie Chern, MD, MSc; Sowmya Nanjappa, MBBS, MD; and John N. Greene, MD
H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida

*Contributed equally to this work.

Citation:
Denham JD, Patel R, Diaz Vera J, Chern J-YJ, Nanjappa S, Greene JN. Pyometra. Consultant. 2018;58(12):351-354.

 

Infections of the uterus are rare and occur most frequently following parturition, as a result of cervical stenosis due to malignancy, following cervical procedures (eg, conization, loop electrosurgical excision procedure), or following uterine evacuation procedures (eg, dilation and curettage/evacuation). Pyometra is the accumulation of pus in the uterine cavity and is most frequently caused by mixed anaerobic organisms.1,2 The symptoms of pyometra can include fever, rigors, pelvic pain, abdominal pain, and vaginal discharge. Clinical findings can include fever, fundal tenderness, cervical motion tenderness, foul-smelling vaginal discharge, and an elevated white blood cell (WBC) count.

We report 2 cases, one in which a patient with cervical adenocarcinoma developed pyometra, and another in which longstanding pyometra mimicked endometrial carcinoma.

 

Case 1

A 59-year-old woman presented with recent onset of chills and fever. Stage II cervical adenocarcinoma had been diagnosed 4 months prior, and she had been treated with 5 cycles of cisplatin chemotherapy and radiation. The last treatment had been 17 days prior to presentation. The patient was a social smoker but had discontinued smoking 2 months after her cancer diagnosis. Her history was otherwise noncontributory.

Physical examination. The patient had a temperature of 38.1°C. The abdomen was soft, nontender, and nondistended. There was no costovertebral angle tenderness. Gynecologic examination revealed scant yellow discharge without frank blood. The cervix was firm (consistent with radiation changes) but without motion tenderness.

Diagnostic tests. Because recent bloodwork had revealed lymphopenia (lymphocyte count, 640/µL), and the patient was presenting with an apparent infection, she was admitted to the hospital. A computed tomography (CT) scan with contrast of the thorax, abdomen, and pelvis (CT-TAP) was performed, the results of which revealed a distended, fluid-filled uterus with myometrial enhancement (Figures 1 and 2). A presumptive diagnosis of pyometra was made. Urine cultures and blood cultures drawn at the time of admission demonstrated no bacterial growth.

Fig 1

fig 2

On hospital day 2, the uterus was successfully evacuated, initial empiric antibiotics (ceftriaxone and doxycycline) were discontinued, and ampicillin-sulbactam was initiated.

Outcome of the case. By hospital day 4, the patient reported feeling better and had been afebrile for 24 hours. Bloodwork revealed a WBC count of 2760/µL and a lymphocyte count of 450/µL. She was deemed stable for discharge to home with a 2-week course of oral amoxicillin-clavulanic acid, 875 mg-125 mg twice daily, with instructions to follow up for further management of her cervical adenocarcinoma.

Case 2

A 71-year-old woman presented with 3 months of green, foul-smelling vaginal discharge requiring the use of 3 to 4 perineal pads per day. The patient initially had been evaluated by her gynecologist, who performed a Papanicolaou test and a workup for vulvovaginal infection. Papanicolaou test results had demonstrated no abnormalities, and reverse-transcriptase polymerase chain reaction (RT-PCR) assay results were negative for bacterial vaginosis or vaginal candidiasis. Despite this, the patient had been prescribed metronidazole but had been forced to discontinue the medication after having developed dyspnea. A second antibiotic (the name of which the patient could not recall) had been prescribed, but again dyspnea had forced its discontinuation.

One month before presentation to our institution, the patient’s gynecologist had performed an endometrial biopsy, the results of which demonstrated “atypical endometrium” but insufficient tissue for a definitive diagnosis. This finding increased the clinical suspicion for endometrial carcinoma, and the patient was referred to our specialized center for further evaluation.

Physical examination. At her initial visit to our outpatient clinic, the patient appeared healthy and afebrile with a chief concern of continued foul-smelling vaginal discharge. Findings of a review of systems were noncontributory. Physical examination findings were unremarkable apart from the vaginal discharge.

Diagnostic tests. Transvaginal ultrasonography revealed a retroverted and retroflexed uterus. A moderate amount of fluid was noted in the uterine fundus with associated hypoechoic soft-tissue debris. Also present was abnormal-appearing soft tissue in the uterine body proximal to the cervix; based on this finding, an examination under anesthesia with dilation and curettage was performed.

Initial microbiological evaluation revealed mixed anaerobic flora, and Gram stain demonstrated an abundance of WBCs and gram-variable rods. An isolate from this sample was processed and sent for further microbiological evaluation via matrix-assisted laser desorption/ionization–time of flight, and Actinomyces turicensis was identified. Pathologic evaluation of the endometrial tissue revealed benign epithelium with reactive change, scant squamous metaplasia, and abundant acute inflammation. Based on these findings, a diagnosis of pyometra was made.

Outcome of the case. The patient was prescribed amoxicillin-clavulanic acid, 875 mg-125 mg twice daily, for 6 months. She reported a marked decrease in the quantity of vaginal discharge in less than 2 months and complete symptom resolution by 6 months.

 

DISCUSSION

Pyometra is an infrequent but potentially serious complication in cervicouterine cancers. The cornerstone of treatment is rapid initiation of antibiotic therapy followed promptly by drainage of fluid from the uterus. The principal complications of untreated pyometra are severe and include uterine rupture/perforation (leading to peritonitis), abscess (intrauterine or intra-abdominal), and sepsis. A review of 14 patients at a single center found that 6 (43%) patients with pyometra experienced uterine perforation as a complication.3

The wide variety of microorganisms reported in cases of pyometra can complicate antibiotic selection. Actinomyces israelii is the most common actinomycete associated with disease in humans. Infections of the female genitourinary tract arising from A israelii have been known to disseminate throughout the peritoneum and involve the liver, thereby clinically mimicking female genitourinary cancer that has metastasized to the liver.4 Despite the clear characterization of A israelii as a frank pathogen, more than 7% of women remain asymptomatically colonized following intrauterine contraceptive device (IUCD) placement.5 Bacteroides species are also common isolates in cases of pyometra.1 Empiric therapy therefore must be broad-spectrum and cover gram-positive and gram-negative organisms. Piperacillin-tazobactam or ceftriaxone and metronidazole are reasonable empiric therapies in cases where cultures are not obtained or where expedited treatment is required (such as in uterine perforation/peritonitis or bacteremia).

Using the index terms pyometra and cancer, a literature review was performed using the PubMed database. The search results were filtered to include only pyometra in humans and was limited to publications in the past 10 years. Based on these criteria, 21 publications were identified. Of these, 10 publications reported cases of pyometra either in a patient with a gynecologic malignancy or as a clinical mimic of a gynecologic malignancy.6-15 The literature review findings are summarized in the accompanying Table. In our review, 1 of 10 patients died as a result of pyometra. The most common complication reported was uterine perforation.6,9,13,14 A “forgotten” IUCD was reported in 2 of 10 cases,8,15 resulting in perforation in one case.15 An interesting finding was an elevation of cancer antigen 125 (CA-125) in 2 of 10 cases.12,13

Table

In summary, pyometra can mimic cervicouterine cancer based on ultrasonography findings, CT findings, and clinical presentation. This condition presents a dilemma to clinicians who frequently diagnose and treat these cancers of the cervix, uterus, and ovaries. Tissue biopsy is necessary to distinguish between malignancy and pyometra, and pyometra should be included in the differential diagnosis of presumptive gynecologic malignancy. Elevations in CA-125, an antigen sometimes associated with ovarian malignancy, are also seen in some cases of non-cancer–related pyometra.12,13 Tissue biopsy also is necessary in these cases to distinguish malignancy from pyometra.

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