A Rare Instance of Streptococcus agalactiae Pyomyoma in a Postmenopausal Patient: A Case Report

Pyomyoma is a rare, but potentially fatal, complication of uterine leiomyoma. Most cases occur in postpartum or postmenopausal patients with vascular disease and arise due to infarction and infection of existing fibroids. The proposed diagnostic triad for pyomyoma includes 1) sepsis or bacteremia; 2) uterine leiomyomata; and 3) no other apparent source of infection. We present a case of a postmenopausal patient who presented with the aforementioned triad and was found to have a pyomyoma, positive for Streptococcus agalactiae.

A 67-year-old woman with no known past medical history presented to the emergency department for altered mental status. Although afebrile, she was tachycardic and hypertensive, with severe hyperglycemia and leukocytosis on initial assessment. Multiple embolic cerebral infarcts were noted on imaging, but workup was negative for a cardiac or vascular source. Her infectious workup was ultimately notable for S agalactiae bacteremia and a fibroid uterus with a rim enhancing fluid collection seen on a computed tomography (CT) abdomen and pelvis scan. Broad spectrum antibiotics were initiated, and she underwent CT-guided drainage of the abscess, which was also positive for S agalactiae. Given continued fevers and elevated white blood cell counts, the patient underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic washout. Intraoperative findings were notable for a pedunculated, necrotic uterine fibroid with purulent material within, and no other apparent gastrointestinal source. The final pathology was benign, and the patient was ultimately discharged to an inpatient rehabilitation facility.

While rare, pyomyoma should be considered for any postpartum or postmenopausal patient with risk factors for, or known, vascular disease, presenting with the triad noted above. The high mortality rate associated with pyomyoma is often due to patients succumbing to overwhelming sepsis, likely related to delays in diagnosis. As such, pyomyoma should be considered in the appropriate context and warrants prompt diagnosis and treatment.