{"paper_id":"06452861-0d00-4bde-a2f0-4760b4ceb479","body_text":"Vol.:(0123456789)\n Discover Medicine           (2025) 2:168  | https://doi.org/10.1007/s44337-025-00370-1\nDiscover Medicine\nCase Report\nMicroabscess within adenomyosis combined with sepsis: a report \nof a rare clinical case\nMengyu Zheng1 · Zhongna Yu1\nReceived: 22 February 2025 / Accepted: 29 May 2025\n© The Author(s) 2025  OPEN\nAbstract\nThis case study describes a rare presentation of an intermuscular abscess associated with uterine adenomyosis and sepsis, \nhighlighting the diagnostic challenges and clinical management of this condition. A 34-year-old woman presented with \nsevere lower abdominal pain, fever, and a history of recurrent dysmenorrhea, unresponsive to initial antibiotic therapy. \nDespite unremarkable findings on transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI), blood cultures \nidentified Escherichia coli, confirming a diagnosis of sepsis. Following the failure of conservative treatment, exploratory \nsurgery revealed a uterine abscess related to adenomyosis, necessitating a total hysterectomy. The patient’s postopera-\ntive recovery was uneventful, with complete resolution of symptoms and infection. This report emphasizes that patients \nwith adenomyosis presenting with persistent lower abdominal pain and high fever may not respond to antibiotics alone. \nRare complications such as abscess formation should be considered, and timely surgical intervention should be pursued \nwhen conservative management proves ineffective.\nKeywords Adenomyosis · Abscess · Sepsis · Case report\n1  Background\nAdenomyosis is a benign gynecological disorder characterized by the presence of endometrial glands and stroma within \nthe myometrium, leading to uterine enlargement and associated symptoms such as dysmenorrhea, menorrhagia, and \npelvic pain. It most commonly affects women of reproductive age, particularly those in their 40 s. A 2015 study estimated \nits overall prevalence at 0.8%, rising to 1.5% in women aged 41–45 years [1 ]. Discrepancies in reported prevalence may \nresult from non-standardized diagnostic criteria and tissue disruption during laparoscopic procedures, complicating \nhistological assessment [2 ]. While relatively common, the exact pathogenesis of adenomyosis remains unclear. Two \nmain theories have been proposed: one suggests that endometrial injury from cesarean sections, uterine curettage, or \nendometritis facilitates the invasion of the basal endometrium into the myometrium, disrupting the junctional zone [3]. \nThe alternative theory attributes adenomyosis to metaplasia of embryonic Müllerian remnants. Adenomyosis can present \nin diffuse or focal forms, often leading to chronic inflammation and fibrosis, which increase susceptibility to infection [4]. \nClinically, about one-third of patients are asymptomatic, while others experience heavy menstrual bleeding, pelvic pain, \nor infertility [5 , 6]. Treatment primarily targets symptom relief, with pharmacological therapies being first-line options. \nRefractory cases may require uterine artery embolization or hysterectomy [1 , 7]. Diagnosis is based on clinical symp -\ntoms, transvaginal ultrasound, and pelvic magnetic resonance imaging (MRI); however, the variability in presentations \n * Zhongna Yu, 397122388@qq.com | 1Department of Obstetrics and Gynecology, The Affiliated People’s Hospital of NingBo University, \n251 Baizhang East Road, Ningbo 315040, Zhejiang, People’s Republic of China.\n\nVol:.(1234567890)\nCase Report  \nDiscover Medicine           (2025) 2:168  | https://doi.org/10.1007/s44337-025-00370-1\noften complicates preoperative diagnosis [8]. Microabscess formation and sepsis in the context of adenomyosis are rare \ncomplications, with only a few cases documented [9 , 10]. This report details a unique case of an intermuscular abscess \nand sepsis caused by adenomyosis, presenting with acute abdominal pain and high fever.\n2  Case\nA 34-year-old woman presented with a 13-year history of secondary dysmenorrhea, along with acute lower abdominal \npain for 3 days and fever for 2 days. Her medical history included a previous cesarean section, pelvic inflammatory disease, \nsevere dysmenorrhea, and 2 years of infertility. Initial laboratory tests at another hospital revealed a white blood cell \n(WBC) count of 18.2 × 10⁹/L, hemoglobin (Hb) level of 76 g/L, and C-reactive protein (CRP) concentration of 2 mg/L. Due \nto recurrent chills, high fever, and persistent abdominal pain, she was admitted to our hospital via the emergency depart-\nment. On admission, her vital signs were as follows: temperature 39.2  ℃, pulse rate 118/min, respiratory rate 19/min, \nand blood pressure 127/75 mmHg. Gynecological examination showed no vulvar abnormalities. The vaginal canal and \nfornices were intact, and the cervix appeared normal. Notably, there was marked cervical motion tenderness. The uterus \nwas anteverted and enlarged, measuring approximately equivalent to a 10-week gestation, with significant tenderness \non palpation. No adnexal masses were detected, and there were no signs of peritoneal irritation. Laboratory findings at \nour hospital showed a WBC count of 12.5 × 10⁹/L, CRP level of 90.38 mg/L, Hb concentration of 82 g/L, and procalcitonin \n(PCT) level of 0.43 ng/mL. Chest computed tomography (CT) findings were unremarkable. A three-dimensional trans-\nvaginal ultrasonography (TVUS) revealed a uterus measuring approximately 100 × 97 × 105 mm with irregular myometrial \nechotexture and endometrial thickening, but no apparent abnormalities in the bilateral adnexal regions. To provide a \nclear overview of the patient’s clinical course, Table  1 outlines the timing of key symptoms, diagnostic investigations, \nand therapeutic interventions from symptom onset through postoperative follow-up.\nBased on the clinical presentation, laboratory findings, and gynecological history, the preliminary diagnoses included \npelvic inflammatory disease (PID), adenomyosis, and moderate anemia. Upon admission, the patient was initiated on a \ncombination of piperacillin sodium-tazobactam and metronidazole (4.5 g + 0.5 g every 8 h) for antimicrobial treatment. \nSupportive care included the intravenous administration of potassium chloride (3.0 g) and vitamin C (2 g) for rehydration, \nalong with indomethacin (100 mg) for antipyresis and analgesia. However, within 24 h, the patient’s body temperature \nescalated to 40.9 °C, accompanied by persistent chills and unrelieved abdominal pain. Blood cultures (aerobic and \nanaerobic) revealed the presence of Escherichia coli, while laboratory tests showed WBC 12.8 × 10⁹/L, CRP 81.31 mg/L, \nHb 70 g/L, and PCT 0.43 ng/mL. In light of the uncontrolled infection, consultation with the infectious disease depart -\nment led to an escalation of antibiotic treatment through the administration of meropenem (1 g every 8 h). Concurrent \ntransvaginal 3D ultrasound revealed uterine enlargement and adenomyosis, with pelvic MRI confirming adenomyosis \nof the uterus. After 3 days of intensive antimicrobial therapy, the patient’s fever persisted, with daily spikes exceeding \n40 ℃, and abdominal pain remained unresolved. To further assess the source of infection, contrast-enhanced ultrasound \n(CEUS) was performed on hospital day 4. The CEUS revealed a hyperechoic area in the posterior uterine wall with irregular \ninternal perfusion, suggestive of a localized abscess within adenomyotic tissue (Fig. 1). Based on these findings, surgical \nintervention was strongly recommended; however, the patient initially declined. Consequently, the infectious diseases \nteam recommended continuing meropenem therapy along with supportive care, including rehydration, analgesics, and \nantipyretics. After 10 days of antimicrobial therapy, the patient’s body temperature normalized, and her abdominal pain \nhad subsided. However, follow-up blood tests revealed a WBC count of 15.5 × 10⁹/L, a CRP level of 20.51 mg/L, an Hb level \nof 79 g/L, and a PCT level of 0.24 ng/mL. Repeated transvaginal ultrasound imaging suggested adenomyosis with abscess \nformation (Fig. 2). Eventually, the patient consented to surgery. A laparoscopic total hysterectomy was performed under \ngeneral anesthesia. Intraoperative findings included a focal abscess and necrosis measuring 1.5 × 1.0 × 0.3 cm between the \nuterine muscle walls (Fig. 3). Cultures of the necrotic tissue confirmed the presence of E. coli. Histopathological analysis \nof the excised uterus revealed extensive neutrophilic infiltration within the myometrium, formation of microabscesses, \nfocal necrosis, and ectopic endometrial glands and stroma consistent with adenomyosis (Fig.  4A, B). These findings \nconfirmed the diagnosis of adenomyosis complicated by localized abscess formation and sepsis.\nPostoperatively, the patient received intravenous cefmetazole (2.0 g every 12 h) for infection prophylaxis and recovery \nsupport. She reported no significant abdominal pain, and her temperature stabilized. The surgical incision healed without \ncomplication. On the first postoperative day, her WBC was 10.1 × 10⁹/L and CRP was 35 mg/L. By postoperative day 3, \ninflammatory markers continued to decline (WBC 7.1 × 10⁹/L, CRP 29 mg/L, Hb 113 g/L). At the 2-week follow-up visit, \n\nVol.:(0123456789)\nDiscover Medicine           (2025) 2:168  | https://doi.org/10.1007/s44337-025-00370-1 \n \n Case Report\nTable 1  Timeline of clinical events, diagnostic evaluations, and interventions\nTime point Clinical features and findings Diagnostic evaluations Interventions\n3 days before admission Onset of acute lower abdominal pain – –\n2 days before admission Onset of high fever (up to 39 °C) with chills WBC 18.2 × 10⁹/L, CRP 2 mg/L Symptomatic analgesic therapy (external hospital)\nDay of admission Persistent fever (39.2 °C), worsening abdominal \npain\nRepeat labs: WBC 12.5 × 10⁹/L, CRP 90.38 mg/L, \nPCT 0.43 ng/mL; TVUS: uterine enlargement\nAdmitted via emergency department; initiated \npiperacillin-tazobactam\nHospital days 1–3 Fever peaked at 40.9 °C; persistent pain; clinical \nsuspicion of sepsis\nBlood cultures (aerobic and anaerobic): E. coli posi-\ntive; MRI and TVUS inconclusive\nEscalated to meropenem; supportive care\nHospital day 4 No clinical improvement; ongoing fever and pain CEUS: hyperechoic lesion in posterior uterine wall \nwith reduced perfusion, suggestive of abscess\nSurgical intervention recommended; initially \ndeclined\nHospital day 10 Partial symptom relief; inflammatory markers \nremained elevated\nRepeat TVUS confirmed intrauterine abscess Patient consented to surgery\nHospital day 11 (operation) Partial symptom relief; inflammatory markers \nremained elevated\nLaparoscopy confirmed intrauterine abscess; histo-\npathology and cultures confirmed E. coli\nTotal laparoscopic hysterectomy\nPostoperative days 1–3 Afebrile; symptoms resolved WBC and CRP gradually normalized Prophylactic antibiotics (cefmetazole)\n2 weeks post-op Full recovery; no recurrence of symptoms Gynecological follow-up confirmed satisfactory \nhealing\n–\n\nVol:.(1234567890)\nCase Report  \nDiscover Medicine           (2025) 2:168  | https://doi.org/10.1007/s44337-025-00370-1\nthe patient remained asymptomatic, and gynecological examination confirmed proper healing of the vaginal stump, \nindicating a favorable postoperative course.\n3  Discussion\nAdenomyosis manifests with diverse clinical symptoms, and its diagnosis can be challenging, especially in the pres -\nence of concurrent pelvic conditions such as leiomyomas, endometrial polyps, endometrial hyperplasia, or endometrial \ncarcinoma [11]. For example, Rezzan Erguvan described a case involving a 54-year-old postmenopausal woman who \npresented with groin pain, night sweats, and hot flashes. Imaging revealed a 95 × 85 mm leiomyomatous lesion, com-\nprising a 53 × 43 mm cystic mass and a 9 × 6 mm intrauterine papillary formation, initially suspected to be malignant. \nFig. 1  Abscess formation in \nthe posterior uterine wall. \nContrast ultrasound of the \nuterus showing an uneven \n85 × 80 × 82 mm area in the \nposterior uterine wall, with \nunclear boundaries and \nuneven internal echoes. \nMultiple small dark areas \nwere observed, the largest of \nwhich was irregularly shaped \nand measured approximately \n19 × 20 × 19 mm. The white \narrow indicates an abscess \nand the red arrow indicates \nadenomyosis\nFig. 2  Uterine enlargement \nwith abscesses (Transvaginal \n3D ultrasound). Transvagi-\nnal 3D ultrasound images \nshowing that the size of \nthe uterine body was about \n102 × 91 × 97 mm, the echo \ndistribution of the posterior \nwall muscle of the uterus was \nuneven, the boundary was \nunclear, and two irregular dark \nareas were visible inside, the \nlarger of which was irregularly \nshaped and measured approx-\nimately 14 × 11 × 16 mm\n\n\nVol.:(0123456789)\nDiscover Medicine           (2025) 2:168  | https://doi.org/10.1007/s44337-025-00370-1 \n \n Case Report\nHowever, intraoperative frozen section analysis confirmed adenomyosis with abscess formation [3 ]. Advances in diag-\nnostic techniques have increased the detection of adenomyosis, with transvaginal ultrasound (TVUS) and magnetic \nresonance imaging (MRI) being the primary imaging modalities [4]. MRI has demonstrated a sensitivity of 70–93% and a \nspecificity of 86–93% for the diagnosis of adenomyosis [12], making it instrumental in confirming diagnoses, assessing \ndisease extent, and identifying concurrent uterine lesions [12, 13]. The diagnosis of adenomyosis on MRI primarily relies \non the presence of junctional zone thickening (≥ 12 mm) on T2-weighted images, along with high-signal lesions in the \nmyometrium. Additional indicators include poorly defined junctional zone borders, high-signal lesions on T1-weighted \nimages, and high-signal linear stripes [14, 15]. However, MRI’s limitations include its high cost, longer examination times, \nand sensitivity to the patient’s menstrual cycle [16]. Furthermore, false-positive or false-negative results can occur, neces-\nsitating the interpretation of imaging by trained professionals. Transvaginal ultrasound (TVS) offers several advantages in \ndiagnosing adenomyosis, including ease of use, rapid execution, lack of radiation exposure, and suitability for outpatient \nor bedside assessments. TVS effectively visualizes uterine structures, aiding in the initial screening for lesions. Diagnostic \ncriteria for adenomyosis on TVS include a spherical uterine shape, myometrial asymmetry, uneven myometrial echo \npatterns, poorly defined boundaries, and the presence of endometrial cysts [9 , 17, 18]. However, TVS is less effective in \ndetecting mild or early-stage adenomyosis and as a means of identifying deep or localized lesions, potentially leading \nto false negatives or missed diagnoses [15, 19]. Although transvaginal ultrasound and pelvic MRI are the main imaging \nmodalities for diagnosing adenomyosis and its complications, chest CT was used in this case as an adjunct investiga-\ntion. Given the patient’s systemic symptoms including persistent high fever and chills chest CT was necessary to rule \nout alternative infectious foci such as pneumonia or septic emboli. The absence of pulmonary findings helped confirm \na localized uterine source of infection.\nIn this case, both TVS and MRI failed to provide a definitive diagnosis, which could be attributed to several factors. \nFirst, focal uterine adenomyosis and abscesses can be difficult to differentiate and are often confused. Second, small \nadenomyotic lesions, particularly those deep within the myometrium or obscured by surrounding tissues, may escape \ndetection. Third, technical factors such as operator expertise and equipment quality can affect ultrasound results, while \nMRI outcomes may depend on scanning parameters and image quality. Finally, understanding of uterine adenomyosis \ncomplicated by abscesses and sepsis remains limited. Additional diagnostic modalities can aid in identifying adenomyosis \nwith abscesses. En-Tzu Wu reported a case of a 49-year-old woman with a long-standing history of adenomyosis who \ndeveloped an unexplained fever lasting 3 weeks. 67 Ga SPECT/CT demonstrated increased tracer uptake in the myome -\ntrium, and hysterectomy confirmed adenomyosis with abscess formation [20]. Similarly, Ka Wang Cheung described a \n49-year-old nulliparous woman with adenomyosis and type 2 diabetes who presented with fever and lower abdominal \npain. CT imaging revealed multiple marginally enhanced low-density collections in the uterus, consistent with uterine \nFig. 3  Postoperative purulent \nsecretions in the uterine \nwall (Intraoperative Image). \nPurulent secretions (red \narrow) were observed in the \nposterior wall muscle layer of \nthe uterus (white arrow) after \nthe operation\n\n\nVol:.(1234567890)\nCase Report  \nDiscover Medicine           (2025) 2:168  | https://doi.org/10.1007/s44337-025-00370-1\nabscesses. Intraoperative findings confirmed pyoadenomyosis, with histological examination verifying uterine adeno -\nmyosis complicated by abscess formation [21].\nContrast-enhanced ultrasound (CEUS) is a diagnostic imaging technique that uses intravenous microbubble contrast \nagents to enhance ultrasound images. This technique improves contrast resolution by amplifying the acoustic impedance \ndifference between blood flow and surrounding tissues, enabling differentiation between diseased and normal tissue. \nCEUS has been widely studied for evaluating blood perfusion in parenchymal organs such as the liver and kidneys, and \nits use in gynecology has focused on diagnosing uterine lesions. CEUS can reveal endometrial microcirculation charac -\nteristics and assess lesion infiltration depth into the myometrium [22]. Studies have shown that contrast enhancement \npatterns in adenomyomas often progress from the periphery toward the center, without surrounding blood flow [23]. \nAbulafia et al. [24] demonstrated that patients with myometrial infiltration exhibited higher microvascular densities in \ntheir tumors compared to those without myometrial involvement, providing a pathological foundation for evaluating \nlesion depth via CEUS. Despite these advancements, the diagnosis of uterine adenomyosis with intermuscular abscesses \nremains rare. In this case, CEUS facilitated a definitive diagnosis, providing clinically valuable insight. CEUS should be \nconsidered when MRI and TVS yield inconclusive results.\nMicroabscess formation in uterine adenomyosis complicated by sepsis often involves mixed infections of anaerobic \nbacteria, aerobic bacteria, and Chlamydia. Studies reporting bacterial cultures from uterine abscesses detect Staphy-\nlococcus epidermidis and E. coli  in 20–30% of cases, with Chlamydia detected in 4.1–25.3% of cases. This condition is \nextremely rare and may result from cesarean sections, endometritis, or compromised immunity leading to uterine abscess \nFig. 4  A Histopathological \nfeatures: neutrophilic infiltra-\ntion and abscess formation. A \nRed arrow: Extensive neutro-\nphil infiltration; Green arrow: \nAbscess; Blue arrow: Necrotic \nlesion; Yellow arrow: Necrotic \nMyometrium; B Histopatho-\nlogical features: endometrial \nglands and myometrium. \nOrange arrow: Myometrium; \nBlack arrow: Endometrial \nglands and interstitium\n\n\nVol.:(0123456789)\nDiscover Medicine           (2025) 2:168  | https://doi.org/10.1007/s44337-025-00370-1 \n \n Case Report\nformation. Additional contributing factors include inadequate drainage of uterine inflammatory secretions, untreated \nchronic pyosis, and adenomyosis invading the uterine muscle wall. Abscess rupture can result in peritonitis or sepsis, \nposing significant risks to the patient.\n4  Conclusion\nThis case illustrates that microabscess within adenomyosis combined with sepsis, although rare, can occur as severe \ncomplications of uterine adenomyosis. Persistent fever and abdominal pain unresponsive to antibiotic therapy should \nprompt reconsideration of the diagnosis, even when initial imaging findings are inconclusive. The integration of CEUS \nwith conventional imaging modalities can improve detection of occult intrauterine infection. When conservative treat -\nment fails, timely surgical intervention is essential to achieve definitive diagnosis and prevent progression to systemic \ninfection.\nAcknowledgements We would like to thank MogoEdit (https:// www. mogoe dit. com) for its English editing during the preparation of this \nmanuscript.\nAuthor contributions Zhongna Yu: Conceptualization, Data curation, Formal analysis, Writing—original draft, Visualization.  Mengyu Zheng: \nWriting—review & editing, Supervision, Project administration.\nFunding No funding was received for this work from any governmental, private, or non-profit entities.\nData availability Declaration Availability of Data and Materials The data supporting the findings of this study are available from the corre -\nsponding author upon reasonable request. However, due to patient confidentiality and institutional policies, access requires prior approval \nfrom the Ethics Committee of The Affiliated People’s Hospital of Ningbo University.  Ethical Approval and Consent to Participate The study was \napproved by Institutional Review Member of the board of directors of The Affiliated People’s Hospital of NingBo University Implemented in \naccordance with the Declaration of Helsinki. The reference number for ethical approval is 2025-N-004. Written informed consent for publica-\ntion of the case details and any accompanying images was obtained from the patient prior to manuscript submission.\nDeclarations \nEthics approval and consent to participate The study was approved by Institutional Review Member of the board of directors of The Affiliated \nPeople’s Hospital of NingBo University Implemented in accordance with the Declaration of Helsinki. The reference number for ethical approval \nis 2025-N-004. Written informed consent for publication of the case details and any accompanying images was obtained from the patient \nprior to manuscript submission.\nConsent for publication Written informed consent for publication of this case report and any accompanying images was obtained from the \npatient. The patient has reviewed the manuscript and understands that all identifying details have been anonymized to ensure confidentiality.\nCompeting interests The authors declare no competing interests.\nOpen Access  This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which \npermits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to \nthe original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You \ndo not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party \nmaterial in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If \nmaterial is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds \nthe permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco \nmmons. org/ licen ses/ by- nc- nd/4. 0/.\nReferences\n 1. Yu O, Schulze-Rath R, Grafton J, Hansen K, Scholes D, Reed SD. Adenomyosis incidence, prevalence and treatment: United States popu-\nlation-based study 2006–2015. Am J Obstet Gynecol. 2020;223:94.e1-94.e10.\n 2. Cunningham RK, Horrow MM, Smith RJ, Springer J. Adenomyosis: a sonographic diagnosis. Radiographics. 2018;38:1576–89.\n 3. Abscess in adenomyosis mimicking a malignancy in a 54-year-old woman - PubMed. https:// pubmed. ncbi. nlm. nih. gov/ 12839 634/. \nAccessed 11 Jan 2025.\n 4. Reinhold C, McCarthy S, Bret PM, Mehio A, Atri M, Zakarian R, et al. 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Use of contrast-enhanced ultrasound in the \nassessment of uterine fibroids: a feasibility study. Ultrasound Med Biol. 2018;44:1901–9.\n 24. Abulafia O, Triest WE, Sherer DM, Hansen CC, Ghezzi F. Angiogenesis in endometrial hyperplasia and stage I endometrial carcinoma. \nObstet Gynecol. 1995;86:479–85.\nPublisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.","source_license":"CC0","license_restricted":false}