Delayed pyometra after uterine artery embolization for uterine leiomyoma: A case report

Uterine artery embolization is a minimally invasive, uterus-preserving treatment for symptomatic uterine leiomyomas that is generally considered safe; delayed infectious complications are uncommon and may be difficult to distinguish from postembolization syndrome. This report presents a case of delayed pyometra associated with a necrotizing leiomyoma following uterine artery embolization. A 41-year-old multiparous woman with a history of two cesarean deliveries underwent bilateral uterine artery embolization for a symptomatic large FIGO type 2 submucosal leiomyoma after declining surgical treatment. Although her symptoms initially improved, she presented three months later with high fever and severe pelvic pain despite only mildly elevated inflammatory laboratory findings. Imaging demonstrated a necrotic leiomyoma with pyometra, and endometrial culture yielded Streptococcus agalactiae. Despite uterine drainage and culture-directed antimicrobial therapy, persistent symptoms ultimately required total laparoscopic hysterectomy. Histopathological examination confirmed extensive coagulative necrosis of the leiomyoma with acute inflammatory infiltration. This case highlights that delayed infectious complications may occur several months after uterine artery embolization for large submucosal leiomyomas and may mimic postembolization syndrome despite relatively mild inflammatory laboratory abnormalities. Careful long-term follow-up and prompt evaluation are essential for timely diagnosis and appropriate management.