Case notes

A 71-year-old woman came to our hospital with lower abdominal pain and a body temperature of 101.3°F (38.5°C). Her obstetric history was T3, P0, A2, L3, and she had undergone bilateral tubal ligation via partial salpingectomy 20 years earlier. The pelvic examination revealed an atrophic vagina and cervix, enlarged uterus, and cervical motion tenderness.

A liquid-based Papanicolaou test of the cervix produced negative findings. Human papillomavirus 59 and 54 were detected with a DNA chip test. Additional testing disclosed a white blood cell count of 16.8 × 10 ³ cells/mm ³ , hemoglobin of 11 g/dL, and a hematocrit of 32.7%. Vaginal cultures were negative. Ultrasonography showed a cyst-like hypoechoic fluid collection measuring 6 × 5 × 5 cm, a sign of possible hydrometra ( Figure 1 ). Computed tomography demonstrated a cauliflower-like invasive hypoechogenic area between the endometrium and myometrium, raising suspicion for endometrial cancer ( Figure 2 ). Subsequently, magnetic resonance imaging displayed a heterogeneously enhancing mass, 6.4 cm in diameter, with a large internal cystic portion, indicative of a large uterine myoma with cystic degeneration ( Figure 3 ).

Cyst-like hypoechoic fluid collection measuring 6 × 5 × 5 cm seen on ultrasonography, suggesting hydrometra.

Kim. No answer in images. Am J Obstet Gynecol 2013 .

Computed tomography revealed cauliflower-like invasive hypoechogenic area between endometrium and myometrium, raising suspicion for endometrial cancer.

Kim. No answer in images. Am J Obstet Gynecol 2013 .

Magnetic resonance imaging showed heterogeneously enhancing mass, 6.4 cm in diameter, with large internal cystic portion. Finding resembled large uterine myoma with cystic degeneration.

Kim. No answer in images. Am J Obstet Gynecol 2013 .

After antibiotic treatment for 1 day, the patient’s fever subsided; however, 4 days after admission, despite continued antibiotics, her fever recurred and was sustained for 3 days. Exploratory surgery uncovered an inflamed, enlarged, right fallopian tube, an enlarged uterus, cul-de-sac adhesions of omentum to the uterus, atrophic bilateral ovaries, and chronic nonspecific inflammation with cystic dilation of the cervix. The myometrium was partly replaced by a yellowish mass. A total abdominal hysterectomy, bilateral salpingo-oophorectomy, and adhesiolysis were performed.

Immunohistochemical staining was positive for actin and CD68, markers useful in a diagnosis of xanthogranulomatous inflammation; staining was negative for CD10 and anaplastic lymphoma kinase. The pathology confirmed xanthogranulomatous inflammation in the endometrium and right fallopian tube.