Suppurative Leiomyoma (Pyomyoma) Mimicking Pyometra in a Postmenopausal Female: A Case Report Highlighting the Role of Adenomiosis and Chronic Salpingitis in Myometrial Abscess Formation.

ABSTRACTBackground: Suppurative leiomyoma, also known as pyomyoma, is an extremely rare clinical entitycharacterized by suppuration, necrosis, and abscess formation within a uterine leiomyoma. In the postantibiotic era, this condition is rarely encountered and frequently misdiagnosed preoperatively as pyometra,pelvic inflammatory disease, or uterine sarcoma.Case Presentation: A 50-year-old postmenopausal female (gravida 5, parity 1) presented with irregularvaginal bleeding, purulent discharge, and a significantly enlarged uterus. Preoperative clinical evaluations ledto a diagnosis of uterine leiomyomas complicated by pyometra. An abdominal hysterectomy with bilateralsalpingectomy was performed. Gross pathological examination revealed multiple, well-demarcated, pus-filledencysted cavities (largest measuring 3.0 x 2.5 cm) embedded deeply within a hypertrophic miometrial wall,while the endometrial cavity remained empty and compressed, thereby excluding central pyometra.Histopathology confirmed acute suppurative endometritis-myometritis with multiple encysted myometrialabscesses (pyomyomas) arising in a background of diffuse myometrial hypertrophy, extensive adenomyosis,and bilateral acute-on-chronic suppurative salpingitis.Conclusions: Pyomyoma should be considered in the differential diagnosis of postmenopausal womenpresenting with a pelvic mass, fever, or purulent discharge, especially when imaging suggests myometrialdegeneration. This case highlights how underlying extensive adenomyosis and chronic salpingitis can serveas structural and infectious conduits, facilitating direct bacterial extension into the myometrium to initiatelocalized pyogenic abscessuation. INTRODUCTIONUterine leiomyomas represent the most common benign neoplasms of the female reproductive tract, affecting up to70-80% of women by the fifth decade of life. While these tumors frequently undergo various forms of asepticdegeneration—such as hyaline, cystic, calcific, or red degeneration—suppurative degeneration, or the formation ofa pyomyoma, is an exceptionally rare complication. A pyomyoma occurs when a leiomyoma becomes infarcted,undergoes necrosis, and is subsequently seeded by pathogenic bacteria via hematogenous, lymphatic, orascending cervical routes.Due to its scarcity, clinicians rarely anticipate this diagnosis, and it is frequently misidentified as pyometra(accumulation of pus within the endometrial cavity), tubo-ovarian abscess, or a necrotic uterine sarcoma. Thisdiagnostic confusion is particularly pronounced in postmenopausal women, in whom diminished uterine vascularitypredisposes leiomyomas to ischemic infarction and subsequent pyogenic colonization. Here, we present a clinicallyand pathologically peculiar case of a 50-year-old postmenopausal patient whose preoperative diagnosis ofpyometra was pathologically redefined as a localized suppurative endometritis-myometritis with encystedpyomyomas, orchestrated by coexisting chronic salpingitis and extensive adenomyosis.CASE PRESENTATIONA 50-year-old postmenopausal female (gravida 5, parity 1; LMP: menopausal) presented with a history of irregular,frank vaginal bleeding, purulent vaginal discharge, pelvic discomfort, and a palpably enlarged uterus. Based onclinical findings and imaging indicating uterine enlargement and fluid collections, a presumptive diagnosis of a largeleiomyomatous uterus complicated by pyometra was made. The patient underwent an elective total abdominalhysterectomy and bilateral salpingectomy. Operative findings reported large uterine fibroids associated with asuspected pyometra.Gross Pathological FindingsThe specimen was received in a formalin-filled container, labeled "uterus, both fallopian tubes," containing a totalabdominal hysterectomy specimen with an attached right salpingectomy and a detached left salpingectomy. Theuterus was brown, smooth, firm, and irregularly shaped, measuring 15.0 x 12.0 x 11.5 cm. Upon bisection, the cutsurface revealed multiple, well-demarcated, pus-filled cavities embedded directly within the thick myometrium; thelargest of these encysted abscesses measured 3.0 x 2.5 cm. Crucially, the endometrial cavity itself was empty,lined by light brown, thin tissue, measuring 4.0 x 3.0 cm, with a myometrial thickness of 3.0 cm. The cervical canalwas completely patent, containing no nabothian cysts or fluid accumulation. The bilateral fallopian tubes weredilated and rubbery; the right measured 6.0 x 1.4 x 1.0 cm, and the left measured 3.0 x 1.8 x 1.5 cm, with cutsurfaces revealing lumens filled with organizing, light-brown purulent tissue. Figure 1. Gross pathology of the bisectioned uterusA high-resolution photograph of the bisected uterus. The markedly hypertrophic and dark brown myometrium is seen. Mostnotably, within the thickness of the myometrial wall, there are multiple well-circumscribed, 'encysted' abscess cavities filled withthick, creamy, light-brownish purulent material. The largest cavity measures approximately 3.0 cm in diameter and is surroundedby an intense rim of congested, red-brown inflammatory reaction, characteristic of a localized pyomyoma/myometrial abscess.Adjacent to the uterus, on the left, the dilated left fallopian tube (1.8x1.5 cm) filled with organizing purulent tissue (pyosalpinx) can be identified. Note that the endometrial cavity is compressed and empty of pus, definitively ruling out a central pyometra. Microscopic ExaminationHistopathological evaluation of twelve duplicated slides confirmed a complex infectious and structural process. Theendometrium demonstrated a weakly active proliferative pattern with overlapping peri-menopausal atrophicchanges, characterized by attenuated glands, reduced stromal cellularity, and focal cystic dilatation. Crucially, theunderlying myometrium demonstrated acute bacterial endometritis-myometritis. Within the myometrial wall, multipleencysted abscesses were identified, characterized by central pools of dense neutrophilic infiltrates, cellular debris,and necrosis, bordered by reactive stromal changes and granulation tissue.Adjacent myometrial sections demonstrated diffuse hypertrophy accompanied by extensive, deep adenomyosis,where benign endometrial glands and stroma were seen embedded within hypertrophic smooth muscle bundles.Multiple subserosal leiomyomas were noted, consisting of classic, benign interlacing fascicles of spindle-shapedsmooth muscle cells devoid of cytological atypia, necrosis, or atypical mitotic figures. The cervix exhibited chronicand active cervicitis with reactive epithelial changes and Nabothian cysts. Both fallopian tubes showed mild tomoderate acute suppurative salpingitis, marked by mucosal neutrophilic infiltration, reactive epithelial changes, andvascular congestion, while preserving the overall structure of the tubal wall.DISCUSSIONA pyomyoma is a diagnostic enigma that typically presents with a triad of a palpable pelvic mass, pain, and fever,accompanied by leukocitosis. In postmenopausal women, the clinical picture is easily confused with a malignantprocess, such as leiomyosarcoma, or pyometra, particularly when vaginal discharge is present. In our case, thesurgical team expected a pyometra. However, gross and microscopic examination demonstrated that theendometrial cavity was empty, and the purulent collections were entirely "encysted" within the myometrium aslocalized abscesses.This pathologically peculiar finding prompts an investigation into the route of infection. In patients with pyomyomas,infection usually ascends from the cervix, or spreads hematogenously or lymphatically. We propose that in thispatient, the infection ascended through the cervix, causing an acute but transient endometritis, and subsequentlyutilized two distinct "conduits" to penetrate deep into the uterine wall:1. Adenomyosis as an infectious conduit: The presence of extensive, diffuse adenomyosis provided preexisting anatomical invaginations of endometrial glands and stroma deep into the hypertrophic myometrium.These glands likely acted as a pathway, allowing the ascending bacterial pathogen to bypass the superficialendometrium and seed directly into the deep, hypertrophic myometrium.2. Bilateral acute-on-chronic salpingitis: The significant dilation and active purulent salpingitis suggest aconcurrent pelvic inflammatory process. The fallopian tubes, filled with organizing purulent debris, may haveserved as a persistent reservoir of bacteria, contributing to the infection of the highly vascularized,degenerating leiomyomas. This case is highly educational because it emphasizes that a clinical presentation of pyometra with an enlargeduterus can mask a localized pyomyoma. Recognizing these distinct pathological entities is crucial, as their clinicalcourses, risks of uterine rupture, and surgical complexities differ significantly. Pathologists and gynecologists mustremain aware of this rare presentation to ensure comprehensive diagnosis and timely surgical intervention.CONCLUSIONSIn conclusion, suppurative leiomyoma (pyomyoma) remains a highly unusual, life-threatening complication inmodern gynecology. This case illustrates a unique pathological correlation where extensive uterine adenomyosisand chronic suppurative salpingitis acted as conduits for deep myometrial bacterial entry, culminating in multipleencysted myometrial abscesses. When managing postmenopausal patients with enlarged uteri, purulent discharge,and suspected pelvic infections, clinicians must maintain a high index of suspicion for pyomyoma, as early surgicalintervention via hysterectomy remains the definitive, life-saving treatment.REFERENCES1. Karaman E, et al. Pyomyoma (suppurative leiomyoma) in a postmenopausal woman: a case report and review of the literature.Journal of Medical Case Reports. 2016;10:112.2. Schmid-Tannwald C, et al. Abscess formation in a uterine fibroid (pyomyoma) - a rare cause of acute abdomen: MRI findings.European Journal of Radiology Extra. 2011;79(2):e27-e30.3. Gorny KR, et al