Pyometra by Clostridium clostridioforme: A Case Report

We report a rare case of pyometra caused by Clostridium clostridioforme (C. clostridioforme) in an elderly woman, illustrating the challenges of managing uncommon microbial etiologies in uterine infections. A 91-year-old woman with a history of paroxysmal atrial fibrillation, type 2 diabetes, and neurogenic bladder developed persistent high fever (>38.5°C) over five days, despite prior antibiotic therapy with ceftriaxone for suspected urinary tract infection. Imaging revealed fluid accumulation within the uterine cavity, consistent with pyometra. Initial treatment with meropenem (MEPM) rapidly improved her condition, with fever and CRP levels decreasing. Cultures from uterine lavage identified Proteus mirabilis and Enterococcus faecalis, both susceptible to MEPM, and her symptoms temporarily resolved, leading to discontinuation of antibiotics. However, five days post-discharge, she experienced recurrent high fever, and repeat lavage revealed C. clostridioforme as the causative pathogen, confirmed by culture and susceptibility testing. Despite oral antibiotics with faropenem and later metronidazole, her fever persisted, necessitating readmission. Daily uterine lavages and intermittent intravaginal metronidazole suppositories gradually led to clinical improvement; the purulent discharge diminished, and body temperature normalized. The infection finally resolved after ongoing local management and a short course of antibiotics for a subsequent urinary tract infection. This case highlights the importance of considering atypical pathogens such as C. clostridioforme in refractory pyometra, especially in elderly or immunocompromised patients. It underscores the need for combined systemic and local therapies and the significance of microbial susceptibility testing to guide treatment. The report emphasizes that managing complex uterine infections requires an integrated approach, and further research is necessary to understand the pathophysiology and optimal management of C. clostridioforme-related pyometra.