Diffuse peritonitis secondary to spontaneous perforation of pyometra in an elderly female

An elderly female in her 80s with multiple comorbidities presented to our emergency department with a 1-day history of progressive abdominal pain. Physical examination revealed peritonitis on abdominal examination. Laboratory examinations were concerning for sepsis. Contrast-enhanced CT of abdomen and pelvis was suspicious for ischaemic colitis and intra-abdominal abscess. In the setting of peritonitis, exploratory laparotomy was performed and found to have a spontaneous rupture of the uterine fundus causing purulent peritonitis. This was managed with the total abdominal hysterectomy and bilateral salpingo-oophorectomy. The patient had a challenging postoperative course complicated by acute kidney injury, congestive heart failure and failure to thrive. Palliative care was consulted for comfort, and she was discharged to hospice. Ruptured pyometra continues to be associated with high mortality despite early and aggressive management, particularly in patients who present with sepsis and organ failure. The diagnosis should be considered in the differential for elderly females who present with emergent surgical abdominal conditions.