Case Presentation: A 73-year-old female, bedbound, nursing home resident with a medical history of ESRD on dialysis, diabetes and hypertension, presented complaining of body aches, malaise, chills and cough. She was afebrile with normal range vitals. CBC showed a WBC of 21.8 with neutrophil predominance. CXR without focal pulmonary findings and urinalysis was negative for infection. Blood cultures showed no growth. Upon admission, the patient was noted to have rising leukocytosis with intermittent fevers and hypotension despite empiric antibiotics (vancomycin and aztreonam) and developed confusion and lethargy. Her HD catheter was removed, but cultures again returned negative. The patient underwent a CT A/P showing a hyperdense pelvic collection with punctate focus of gas and layering debris. Antibiotics were changed to ceftriaxone, metronidazole and doxycycline to treat presumed pelvic infection. The patient had an MRI pelvis which showed progressive hydrometra with persistent small foci of gas most consistent with pyometra. She underwent suction D&C during which frank stool was found in the vaginal vault and 300 cc of pus was evacuated from the uterus. Following the procedure, the patient had rapid clinical improvement.
Discussion: Sepsis is a common hospital admission diagnosis. Elderly, nursing home residents are more susceptible to developing sepsis than their younger, independent counterparts. Although respiratory and urinary tract infections are the most common etiologies, the underlying cause of sepsis can be more difficult to diagnose in the elderly due to atypical presentations. In our case, the patient’s rapid clinical decline and non-focal symptoms required the team to use various modalities to look beyond the common etiologies of sepsis. Ultimately, the team uncovered pyometra as her source of infection. Pyometra is a rare infection characterized by pus in the uterus. Patients may present with malodorous vaginal discharge, pelvic pain and bleeding, but many cases present without localized symptoms. Pyometra is slightly more common in postmenopausal women due to cervical os stenosis. Underlying pelvic malignancy or history of radiation are the most common risk factors. In our patient, ascending bacterial spread from fecal matter found in the vagina led to the development of pyometra. Her full dependency on others for activities of daily living made her more vulnerable to developing this rare infection. Definitive management of pyometra requires D&C as the infection is otherwise self-contained in the uterus (acting as an abscess) and impenetrable by antibiotics alone. In our case, despite the risk of D&C, source control was imperative to her survival and resulted in resolution of her infection.
Conclusions: Sepsis is a common cause of hospitalization for nursing home patients, however pyometra is an uncommon etiology. This case highlights the importance of uncovering and treating the source of sepsis for patients’ clinical recovery.