PMC7695505_01
Plain computed tomography (CT) on admission showing ascites accumulation and fluid-containing uterine fibroids.
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On abdominal computed tomography (CT) (Figure 1), we observed ascites accumulation and fluid-containing uterine fibroids of approximately 10 cm in size.
Clinical course after admission. Since the patient was initially in severe septic shock, intensive care was given according to the damage control strategy. As a result, her circulatory dynamics became stable by the end of the day. NAD, noradrenaline; AD, adrenaline; OAM; open abdomen management; PMX-DHP, direct hemoperfusion with polymyxin B-immobilized fibers; HR, heart rate; MAP, mean arterial pressure; BT, body temperature.
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 Figure 2 shows the patient's clinical course, and Figure 3 shows her laboratory data after admission.
Changes in laboratory data after admission. Inflammatory parameters, renal function, and clotting ability of blood were generally stable within a week. DCS, damage control surgery; WBC, white blood cell; Plt, platelet; CRP, C-reactive protein.
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 Figure 2 shows the patient's clinical course, and Figure 3 shows her laboratory data after admission.
Operative findings on second-look surgery, with a pale small intestine, indicating that it might become ischemic (circle).
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The small intestine was ischemic; hence, we again performed OAM for temporary abdominal closure (Figure 4).
Pathological findings. (a) Appearance of pyometra. (b) A solid white mass of approximately 10 cm in size, and yellowish fragile areas with necrosis or abscess formation in the mass (circles). (c) Histologically, there was no obvious malignancy. There were few positive findings of smooth muscle markers (SMA, Caldesmon) using immunostaining. Deposition of collagen fiber bundles was relatively prominent in the stroma, and a flower bud-like array was recognized. These findings suggested that this mass was a fibroma rather than a leiomyoma. An abscess with massive neutrophil infiltration was present in the mass, and the surrounding serosal surface showed inflammatory cell infiltration with fibrin deposition. (d) A large mass of Gram-positive bacteria (arrowheads) was found inside the abscess.
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Pathological findings (Figure 5) included a fibroma with abscess formation, peritonitis, adenomyosis, endometrial polyp, and endometrial stromal nodule of the uterine corpus. Examination of the uterus for pyometra revealed yellowish fragile areas with necrosis or abscess formation (Figures 5(a) and 5(b)). No malignancy was identified on histological examination (Figure 5(c)), suggesting a fibroma with inflammatory cell infiltration.