Medroxyprogesterone
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Pyometra: case report A 16-year-old girl developed pyometra during treatment with medroxyprogesterone for abnormal uterine bleeding-ovulatory. The girl, who had a low-grade fever, abdominal pain and abnormal vaginal discharge, presented to the emergency department. She had a significant history of hypothyroidism, hemimegalencephaly, hemispherectomies, neurogenic bladder with recurrent urinary tract infections (UTIs), intellectual disability, intractable epilepsy with daily seizures. She had been receiving depot medroxyprogesterone injection [Depo-provera (Pfizer); dosage not stated] since the age of 10 years. She was amenorrheic for several years, but light vaginal bleeding occurred 1 month prior to the presentation. She received the last dose of medroxyprogesterone around 1 month before the presentation. At presentation, she was afebrile, normotensive and tachycardic. Pelvic ultrasonography revealed an enlarged endometrial canal of 4.2cm containing fluid and debris, which concerning for haematometra. Then, she was transferred to the operating room where cervical dilation, drainage of the haematometra and placement of a levonorgestrel IUD was performed under unspecified anaesthesia. A hysteroscopy revealed thick green/yellow purulent fluid within the endometrial cavity, consistent with pyometra. The girl underwent suction curette to remove this fluid. Thereafter, she was treated with IV cefoxitin and oral doxycycline for 24 hours and discharged home with oral doxycycline for a total of 14 days. Cultures of this fluid showed growth of Proteus mirabilis. Hence, cefdinir was added to antibiotic therapy for 10 days. Her symptoms improved with the antibiotic therapy, but she presented again to the emergency room with decreased appetite and abdominal pain. Based on pelvic ultrasonography, recurrent pyometra was diagnosed. Therefore, IV gentamicin and clindamycin was started, and suction curette was again performed to drain the endometrial cavity. Thereafter, the cavity was copiously irrigated with sodium chloride [normal saline] to wash out any remaining purulence. Cultures from uterine evacuation again showed growth of Proteus mirabilis. She recovered following IV antibiotics therapy and uterine evacuation. She was discharged on 14 days course of cotrimoxazole [trimethoprim/sulfamethoxazole]. After 8 days, she again presented to the emergency department with abdominal pain and vaginal discharge. Pelvic ultrasound showed fluid collection within the uterus. Treatment with IV antibiotics was again started. Subsequent MRI revealed pyometra with no obvious structural abnormality. Hysteroscopy showed vesicular lesions. For the prevention of fluid accumulation, a Foley catheter was placed in the uterine cavity. Enterococcus faecalis was detected on the uterine fluid culture. Therefore, she was discharged on clindamycin and levofloxacin. Histopathology of vesicular lesions revealed benign endometrium with scattered frequent plasma cells, consistent with chronic endometritis. After the physician consultation, laparoscopic h
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