Thanks to Dr. Chandra Baker and Dr. Susan M. Ascher, Georgetown University Hospital.
Clinical History
The patient is a 47 year old female, three weeks status post uneventful uterine fibroid embolization. She presented to the ED with low grade fever, elevated white blood cell count, diffusely tender abdomen, positive urinalysis and one day history of severe, sudden onset periumbilical pain, diarrhea and brownish vaginal discharge. The patient's medical history was significant for sarcoidosis and at the time of presentation, she was being treated with oral Levaquin for bronchitis. The patient was admitted, started on broad-spectrum antibiotics and a CT scan of the abdomen and pelvis was obtained.
Differential Diagnosis
Infected Uterine Fibroid (Myometritis)
Endometritis
Appendicitis
Post embolization syndrome
Imaging Findings
Contrast-enhanced CT of the Abdomen and Pelvis: Axial and reformatted sagittal images show non-enhancing uterine leiomyomas. The dominant fibroid in the uterine fundus has subtle high attenuation suggesting hemorrhage and contains foci of gas. Adjacent fat stranding is present. No drainable fluid collection is seen. The appendix, kidneys and ureters are normal.
Discussion
Gas within fibroids post UAE may be a normal finding; however, the presence of gas in the appropriate clinical setting is worrisome for anaerobic infection within the fibroid. Infection of uterine fibroids following embolization continues to be a rare complication. Risk factors for infection of uterine fibroids have not been clearly defined, however retrospective data suggests the risk of infection may be greater in submucosal fibroids.
The distinction between myometrial and endometrial infection is largely academic, as endometritis is partially defined by its extension into the myometrium. Symptoms and treatment are identical. Symptoms from infection of the fibroid may mimic post embolization syndrome. The time of presentation distinguishes these entities from one another, as post embolization syndrome symptoms have usually resolved within a week of embolization, while fever and abdominal pain associated with an infected fibroid are generally late complications, as demonstrated in this patient. A normal appendix excludes the diagnosis of appendicitis.
These cases can usually be treated conservatively, with IV antibiotics only. More complicated cases, however, require hysterectomy and two fatalities from overwhelming sepsis following UAE have been reported.
Our patient was treated in the hospital with intravenous antibiotics for six days Her white blood cell count trended into the normal range by day 5 and she defervesced within 2 days of admission. The patient was discharged home on oral antibiotics.
References
Rajan DK, Beecroft JR, Clark, TWI, et al. Risk of intrauterine infectious complications after uterine artery embolization. J Vasc Interv Radiol 2004;15:1415-21.
Vashisht A, Studd J, Carey A, et al. Fatal septicaemia after fibroid embolization. Lancet 1999; 354:307-08.De Blok S, de Vries C, Prinssen HM, et al. Fatal sepsis after uterine artery embolization with microspheres. J Vasc Interv Radiol 2003; 14:779-83.
Kitamura Y, Ascher SM, Cooper CC, et al. Imaging Manifestations of Complications Associated with Uterine Artery Embolization, RadioGraphics 2005; 25:S119-S132