International Journal of Gynecological Pathology 33:511–514, Lippincott Williams & Wilkins, Baltimore r 2014 International Society of Gynecological Pathologists
Case Report
Endometrial Pneumatosis (Emphysematous Endometritis) Yee Jia Chua,
M.B.B.S.,
Suzanne Meharry, F.R.A.N.Z.C.O.G., Steven Harding, and Colin J. R. Stewart, F.R.C.P.A.
F.R.A.N.Z.C.O.G.,
Summary: Endometrial pneumatosis, also referred to as pneumopolycystic or emphysematous endometritis, is a rare condition reported only twice previously in the literature and only once as an isolated finding. We report a case of endometrial pneumatosis in a 43-yr-old patient who underwent hysterectomy and bilateral salpingectomy for treatment of a symptomatic uterine leiomyoma. No predisposing factors towards pneumatosis were identified and in particular there was no evidence of immune impairment, diabetes mellitus, uterine infection, or prior surgical intervention. Endometrial pneumatosis remains an enigmatic condition of uncertain etiology but it appears to be self-limited with no known pathologic sequelae. Key Words: Endometrium—Pneumatosis—Emphysematous—Pneumopolycystic—Histopathology.
pneumatosis include diabetes mellitus, immunosuppression, and tissue ischemia or infarction. Noninfective pneumatosis can be caused by mechanical factors such as mucosal disruption and increased intraluminal pressure within a hollow viscus as these predispose towards air tracking into submucosal spaces. Trauma and iatrogenic factors including surgery and instrumentation/biopsy may be relevant in this context. In general, noninfective pneumatosis is more likely to be a clinically incidental finding on radiologic or pathologic investigation, and spontaneous resolution can be expected in the majority of cases. However, sometimes no obvious predisposing cause for pneumatosis is found, whereas, conversely, multiple factors, both infective and noninfective, are probably contributory in some patients, for example those with necrotic malignant fistulas and immunosuppression secondary to chemotherapy. Pneumatosis of the female genital tract is rare but occurs most commonly in the vagina or cervix (emphysematous vaginitis or cervicitis) (10–12). One case of ovarian pneumatosis has also been described (13). To our knowledge, pneumatosis involving the endometrium has been described only twice previously, and only once as an isolated finding (14,15). In this report, we describe a case of
Pneumatosis, the presence of air or gas within tissue spaces, has been described in many organs, most commonly in the intestine (pneumatosis cystoides intestinalis) and in the skin (subcutaneous emphysema) (1,2). Other less commonly reported sites include the stomach (3–5), gallbladder (6), pancreas (7), parotid gland (8), urinary tract (9), and the female genital tract (10–15). The etiology of pneumatosis is not completely understood but 2 broad categories, infective and noninfective, are recognized. Infective pneumatosis can be caused by anaerobic gas-producing bacteria, most commonly Clostridium perfringens, and result in life-threatening conditions including gas gangrene. Clearly, there is urgent need for early diagnosis and treatment in such cases as these have significant mortality. Factors that increase the risk of infective
From the Departments of Histopathology (Y.J.C., C.J.R.S.); Obstetrics and Gynecology (S.M., S.H.), King Edward Memorial Hospital, Perth; and School for Women’s and Infants’ Health (C.J.R.S.), University of Western Australia, Crawley, WA. The authors declare no conflict of interest. Address correspondence and reprint requests to Colin J. R. Stewart, FRCPA, Department of Histopathology, King Edward Memorial Hospital, Bagot Road, Subiaco, Perth, WA 6008. E-mail: [email protected].
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DOI: 10.1097/PGP.0000000000000090
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Y. J. CHUA ET AL.
endometrial pneumatosis in which no obvious predisposing or causative factor was identified. CASE REPORT A 43-yr-old woman presented with a 12-mo history of worsening menorrhagia and dyspareunia. She had no significant medical history and in particular no history of immunosuppression, diabetes, or hormonal therapy. Clinical examination showed a 16-wk-size uterus, which was mobile on bimanual examination. Imaging studies revealed an enlarged uterus 130 98 109 mm with a large solid mass in the anterior uterine body consistent with an intramural fibroid. The endometrium appeared of normal thickness (9 mm) and no adnexal pathology was evident. Routine hematologic and serological investigations were normal other than mild iron deficiency anemia. The patient subsequently underwent total abdominal hysterectomy and bilateral salpingectomy without complications. She had not had any prior instrumentation or biopsy of the endometrium. Postoperative clinical follow-up was uneventful 4 mo after surgery.
Pathology Findings The uterus and cervix was received unfixed directly upon removal and grossly normal fallopian tubes were submitted separately. External examination showed a globoid uterine corpus up to 145 mm diameter with a smooth serosal surface and normalappearing cervix. The specimen was opened coronally revealing a striking multicystic cobblestone-like appearance of the entire anterior and posterior endometrial surfaces (Fig. 1). The cysts were of uniform size approximately 2 to 3 mm diameter and they were confined to the superficial endometrium. The endometrium otherwise was up to 9 mm thick with a fleshy soft appearance. The lower segment and cervical mucosal surfaces were normal other than mild congestion. Sections of the myometrium revealed an 84 mm grossly typical intramural fibroid within the anterior wall. The posterior myometrium was normal. Histologic examination revealed multiple irregular and partly collapsed vesicular spaces within the superficial endometrial stroma extending close to the surface epithelium (Fig. 2). The spaces were of variable caliber, the largest apparently arising as a consequence of fusion of smaller stromal cavities. Most spaces appeared empty but some larger cavities showed partial, valve-like intralumenal stromal folds, Int J Gynecol Pathol Vol. 33, No. 5, September 2014
FIG. 1. The opened hysterectomy specimen reveals multiple raised cystic spaces on the endometrial mucosal surface. Note that the lower segment mucosa (right) and the myometrium appear normal.
thin proteinaceous fluid, and occasional sloughed cellular elements. The spaces appeared to be lined by slightly compressed endometrial stroma in which residual glandular and vascular elements were evident. No distinct epithelial or endothelial lining was identified, and immunostaining for cytokeratin, CD31, CD34, FLI-1, and D2-40 was negative in several representative blocks (Fig. 3). Occasional stromal histiocytes were present highlighted by CD68 immunostaining but there was no significant inflammatory cell infiltrate and multinucleated cells were not identified. The process was limited to the endometrium which otherwise showed a normal late secretory pattern. The intramural fibroid was a benign leiomyoma with focal degenerative changes, whereas the cervix and fallopian tubes were normal. Following the initial histologic assessment and consideration of a possible pneumatosis-like process, residual intact endometrial cysts in the gross specimen were punctured under water and some appeared to release gas bubbles consistent with entrapped air. DISCUSSION Endometrial pneumatosis is a rare entity with only 2 cases reported previously (14,15). The first case was a 32-yr-old woman who had just had an uncomplicated vaginal delivery of her second child. She was noted to have numerous cysts throughout her vulva, vagina, and cervix, which ‘‘popped’’ upon compression. Exploration of her uterus showed similar cysts in the endometrium and pelvic x-rays revealed ‘‘innumerable gas-containing cystic structures outlining the entire uterus.’’ Histologic examination of
ENDOMETRIAL PNEUMATOSIS
513
FIG. 2. (A) There is polypoid elevation of the endometrium (left) due to a large intramucosal cyst. The background endometrium (right) shows normal secretory appearances. (B) Higher magnification of the smaller cysts shows these to be lined by stroma with intervening residual glandular and vascular elements. There is no inflammatory cell component.
vaginal and cervical biopsies showed emphysematous vaginitis/cervicitis with multiple empty and variably sized cystic spaces present within edematous stroma. These were described as being variably lined by ‘‘endothelial type cells,’’ multinucleated giant cells, or connective tissue stroma, and there was a mild nonspecific inflammatory infiltrate. The endometrium was not examined histologically. The patient’s condition resolved spontaneously 2 wk postpartum (14). The second case, described by Val-Bernal et al. (15), provided the first histologic description of pneumatosis limited to the endometrium. A previously well 49-yr-old woman investigated for irregular menses and hypermenorrhea of 12-mo duration was found on ultrasonography to have a diffusely thickened endometrium and a 15 mm anechoic cystic structure within the posterior uterine wall. Histologic examination demonstrated proliferative endometrium, simple endometrial hyperplasia,
and empty cystic stromal spaces within the endometrial mucosa similar to those described in the present case. The patient was well at follow-up 3 mo later. Although this case was reported under the title of ‘‘pneumopolycystic endometritis,’’ similar to the case described by Perkins (14), the authors commented that ‘‘endometrial pneumatosis’’ may have been a more appropriate terminology as there was no significant inflammatory component, and we have used the latter term in this report. The histologic features of the current case are similar to those described in noninfective pneumatosis generally where the lining of the vesicles is composed of compressed but otherwise normal stromal elements. Multinucleate histiocytes may be seen around the cyst spaces but these were not identified in the current case although small clusters of histiocytes were present. The differential diagnosis of pneumatosis could include an angiomatous or
FIG. 3. Consecutive sections show no evidence of an epithelial or endothelial lining to the cysts on hematoxylin and eosin (A), cytokeratin (B) and CD34 (C) staining, respectively.
Int J Gynecol Pathol Vol. 33, No. 5, September 2014
514
Y. J. CHUA ET AL.
angiectatic process, or cystic dilatation of glandular elements, but these were excluded by appropriate immunohistochemical investigations. It is also worth considering whether the endometrial spaces could have represented an artefact, particularly as these were not identified on preoperative imaging. However, in contrast to the case of Val-Bernal et al. (15), where a single hypoechoic space was seen on ultrasonography, the current case demonstrated innumerable 2- to 3-mm spaces within the endometrial mucosa which were likely beyond the resolution of imaging. As is normal practice in our hospital, the hysterectomy specimen was transferred to the histopathology laboratory unfixed and directly following removal making postoperative artefact highly unlikely, particularly as we have not observed similar changes in other uterine specimens. In the current case, no definite etiological factors for pneumatosis were identified and in particular the patient had no other significant medical conditions and no prior instrumentation or biopsy of the uterus. Although it is possible that the large leiomyoma led to mucosal disruption or produced obstruction of the uterine cavity thereby causing increased intralumenal pressure, the tumor did not involve the endometrium directly and the pneumatosis involved the anterior and posterior mucosal surfaces equally. It is also unclear whether the endometrial pneumatosis may have contributed towards the patient’s symptoms of menorrhagia and dyspareunia but given their duration it seems more likely that these were related to the leiomyoma. In summary, a third case of endometrial pneumatosis (emphysematous or pneumopolycystic endometritis) is presented. This curious condition appears
Int J Gynecol Pathol Vol. 33, No. 5, September 2014
self-limited clinically but the etiology remains uncertain.
REFERENCES 1. Khalil PN, Huber-Wagner S, Ladurner R, et al. Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis. Eur JMed Res 2009;14:231–9. 2. Samlaska CP, Maggio KL. Subcutaneous emphysema. Adv Dermatol 1996;11:117–51. 3. D’Cruz R, Emil S. Gastroduodenal emphysema. J Pediatr Surg 2008;43:2121–3. 4. Al-Jundi W, Shebl A. Emphysematous gastritis: case report and literature review. Int J Surg 2008;6:e63–6. 5. Grayson DE, Abbott RM, Levy AD, et al. Emphysematous infections of the abdomen and pelvis: a pictorial review. Radiographics 2002;22:543–61. 6. Sonmez G, Ozturk E, Mutlu H, et al. Education and imaging. Hepatobiliary and pancreatic: emphysematous cholecystitis. J Gastroenterol Hepatol 2007;22:2035. 7. Kvinlaug K, Kriegler S, Moser M. Emphysematous pancreatitis: a less aggressive form of infected pancreatic necrosis? Pancreas 2009;38:667–71. 8. Luaces R, Ferreras J, Patino B, et al. Pneumoparotid: a case report and review of the literature. J Oral Maxillofac Surg 2008;66:362–5. 9. Joseph RC, Amendola MA, Artze ME, et al. Genitourinary tract gas: imaging evaluation. Radiographics 1996;16:295–308. 10. Choudhury AP, Rashid M, Goddard R, et al. Pneumatosis cystoides of cervix and vagina in a patient with congestive cardiac failure. J Obstet Gynaecol 2009;29:165–7. 11. McCallion JS, Parkin DE. Emphysematous vaginitis masquerading as carcinoma of the cervix. Case report. B J Obstet Gynaecol 1988;95:309–11. 12. Mautner LS. Vaginitis emphysematosa. Can Med Assoc J 1958;80:643–7. 13. Wang Y, Topran EA, Tavassoli F. Pneuamtosis ovarii (emphysematous changes in the ovary): a case report. Int J Gynecol Pathol 2008;27:531–3. 14. Perkins MB. Pneumopolycystic endometritis. Am J Obstet Gynecol 1960;80:332–6. 15. Val-Bernal JF, Villoria F, Cagigal ML, et al. Pneumopolycystic endometritis. Am J Surg Pathol 2006;30:258–61.
Case Report
Endometrial Pneumatosis (Emphysematous Endometritis) Yee Jia Chua,
M.B.B.S.,
Suzanne Meharry, F.R.A.N.Z.C.O.G., Steven Harding, and Colin J. R. Stewart, F.R.C.P.A.
F.R.A.N.Z.C.O.G.,
Summary: Endometrial pneumatosis, also referred to as pneumopolycystic or emphysematous endometritis, is a rare condition reported only twice previously in the literature and only once as an isolated finding. We report a case of endometrial pneumatosis in a 43-yr-old patient who underwent hysterectomy and bilateral salpingectomy for treatment of a symptomatic uterine leiomyoma. No predisposing factors towards pneumatosis were identified and in particular there was no evidence of immune impairment, diabetes mellitus, uterine infection, or prior surgical intervention. Endometrial pneumatosis remains an enigmatic condition of uncertain etiology but it appears to be self-limited with no known pathologic sequelae. Key Words: Endometrium—Pneumatosis—Emphysematous—Pneumopolycystic—Histopathology.
pneumatosis include diabetes mellitus, immunosuppression, and tissue ischemia or infarction. Noninfective pneumatosis can be caused by mechanical factors such as mucosal disruption and increased intraluminal pressure within a hollow viscus as these predispose towards air tracking into submucosal spaces. Trauma and iatrogenic factors including surgery and instrumentation/biopsy may be relevant in this context. In general, noninfective pneumatosis is more likely to be a clinically incidental finding on radiologic or pathologic investigation, and spontaneous resolution can be expected in the majority of cases. However, sometimes no obvious predisposing cause for pneumatosis is found, whereas, conversely, multiple factors, both infective and noninfective, are probably contributory in some patients, for example those with necrotic malignant fistulas and immunosuppression secondary to chemotherapy. Pneumatosis of the female genital tract is rare but occurs most commonly in the vagina or cervix (emphysematous vaginitis or cervicitis) (10–12). One case of ovarian pneumatosis has also been described (13). To our knowledge, pneumatosis involving the endometrium has been described only twice previously, and only once as an isolated finding (14,15). In this report, we describe a case of
Pneumatosis, the presence of air or gas within tissue spaces, has been described in many organs, most commonly in the intestine (pneumatosis cystoides intestinalis) and in the skin (subcutaneous emphysema) (1,2). Other less commonly reported sites include the stomach (3–5), gallbladder (6), pancreas (7), parotid gland (8), urinary tract (9), and the female genital tract (10–15). The etiology of pneumatosis is not completely understood but 2 broad categories, infective and noninfective, are recognized. Infective pneumatosis can be caused by anaerobic gas-producing bacteria, most commonly Clostridium perfringens, and result in life-threatening conditions including gas gangrene. Clearly, there is urgent need for early diagnosis and treatment in such cases as these have significant mortality. Factors that increase the risk of infective
From the Departments of Histopathology (Y.J.C., C.J.R.S.); Obstetrics and Gynecology (S.M., S.H.), King Edward Memorial Hospital, Perth; and School for Women’s and Infants’ Health (C.J.R.S.), University of Western Australia, Crawley, WA. The authors declare no conflict of interest. Address correspondence and reprint requests to Colin J. R. Stewart, FRCPA, Department of Histopathology, King Edward Memorial Hospital, Bagot Road, Subiaco, Perth, WA 6008. E-mail: [email protected].
511
DOI: 10.1097/PGP.0000000000000090
512
Y. J. CHUA ET AL.
endometrial pneumatosis in which no obvious predisposing or causative factor was identified. CASE REPORT A 43-yr-old woman presented with a 12-mo history of worsening menorrhagia and dyspareunia. She had no significant medical history and in particular no history of immunosuppression, diabetes, or hormonal therapy. Clinical examination showed a 16-wk-size uterus, which was mobile on bimanual examination. Imaging studies revealed an enlarged uterus 130 98 109 mm with a large solid mass in the anterior uterine body consistent with an intramural fibroid. The endometrium appeared of normal thickness (9 mm) and no adnexal pathology was evident. Routine hematologic and serological investigations were normal other than mild iron deficiency anemia. The patient subsequently underwent total abdominal hysterectomy and bilateral salpingectomy without complications. She had not had any prior instrumentation or biopsy of the endometrium. Postoperative clinical follow-up was uneventful 4 mo after surgery.
Pathology Findings The uterus and cervix was received unfixed directly upon removal and grossly normal fallopian tubes were submitted separately. External examination showed a globoid uterine corpus up to 145 mm diameter with a smooth serosal surface and normalappearing cervix. The specimen was opened coronally revealing a striking multicystic cobblestone-like appearance of the entire anterior and posterior endometrial surfaces (Fig. 1). The cysts were of uniform size approximately 2 to 3 mm diameter and they were confined to the superficial endometrium. The endometrium otherwise was up to 9 mm thick with a fleshy soft appearance. The lower segment and cervical mucosal surfaces were normal other than mild congestion. Sections of the myometrium revealed an 84 mm grossly typical intramural fibroid within the anterior wall. The posterior myometrium was normal. Histologic examination revealed multiple irregular and partly collapsed vesicular spaces within the superficial endometrial stroma extending close to the surface epithelium (Fig. 2). The spaces were of variable caliber, the largest apparently arising as a consequence of fusion of smaller stromal cavities. Most spaces appeared empty but some larger cavities showed partial, valve-like intralumenal stromal folds, Int J Gynecol Pathol Vol. 33, No. 5, September 2014
FIG. 1. The opened hysterectomy specimen reveals multiple raised cystic spaces on the endometrial mucosal surface. Note that the lower segment mucosa (right) and the myometrium appear normal.
thin proteinaceous fluid, and occasional sloughed cellular elements. The spaces appeared to be lined by slightly compressed endometrial stroma in which residual glandular and vascular elements were evident. No distinct epithelial or endothelial lining was identified, and immunostaining for cytokeratin, CD31, CD34, FLI-1, and D2-40 was negative in several representative blocks (Fig. 3). Occasional stromal histiocytes were present highlighted by CD68 immunostaining but there was no significant inflammatory cell infiltrate and multinucleated cells were not identified. The process was limited to the endometrium which otherwise showed a normal late secretory pattern. The intramural fibroid was a benign leiomyoma with focal degenerative changes, whereas the cervix and fallopian tubes were normal. Following the initial histologic assessment and consideration of a possible pneumatosis-like process, residual intact endometrial cysts in the gross specimen were punctured under water and some appeared to release gas bubbles consistent with entrapped air. DISCUSSION Endometrial pneumatosis is a rare entity with only 2 cases reported previously (14,15). The first case was a 32-yr-old woman who had just had an uncomplicated vaginal delivery of her second child. She was noted to have numerous cysts throughout her vulva, vagina, and cervix, which ‘‘popped’’ upon compression. Exploration of her uterus showed similar cysts in the endometrium and pelvic x-rays revealed ‘‘innumerable gas-containing cystic structures outlining the entire uterus.’’ Histologic examination of
ENDOMETRIAL PNEUMATOSIS
513
FIG. 2. (A) There is polypoid elevation of the endometrium (left) due to a large intramucosal cyst. The background endometrium (right) shows normal secretory appearances. (B) Higher magnification of the smaller cysts shows these to be lined by stroma with intervening residual glandular and vascular elements. There is no inflammatory cell component.
vaginal and cervical biopsies showed emphysematous vaginitis/cervicitis with multiple empty and variably sized cystic spaces present within edematous stroma. These were described as being variably lined by ‘‘endothelial type cells,’’ multinucleated giant cells, or connective tissue stroma, and there was a mild nonspecific inflammatory infiltrate. The endometrium was not examined histologically. The patient’s condition resolved spontaneously 2 wk postpartum (14). The second case, described by Val-Bernal et al. (15), provided the first histologic description of pneumatosis limited to the endometrium. A previously well 49-yr-old woman investigated for irregular menses and hypermenorrhea of 12-mo duration was found on ultrasonography to have a diffusely thickened endometrium and a 15 mm anechoic cystic structure within the posterior uterine wall. Histologic examination demonstrated proliferative endometrium, simple endometrial hyperplasia,
and empty cystic stromal spaces within the endometrial mucosa similar to those described in the present case. The patient was well at follow-up 3 mo later. Although this case was reported under the title of ‘‘pneumopolycystic endometritis,’’ similar to the case described by Perkins (14), the authors commented that ‘‘endometrial pneumatosis’’ may have been a more appropriate terminology as there was no significant inflammatory component, and we have used the latter term in this report. The histologic features of the current case are similar to those described in noninfective pneumatosis generally where the lining of the vesicles is composed of compressed but otherwise normal stromal elements. Multinucleate histiocytes may be seen around the cyst spaces but these were not identified in the current case although small clusters of histiocytes were present. The differential diagnosis of pneumatosis could include an angiomatous or
FIG. 3. Consecutive sections show no evidence of an epithelial or endothelial lining to the cysts on hematoxylin and eosin (A), cytokeratin (B) and CD34 (C) staining, respectively.
Int J Gynecol Pathol Vol. 33, No. 5, September 2014
514
Y. J. CHUA ET AL.
angiectatic process, or cystic dilatation of glandular elements, but these were excluded by appropriate immunohistochemical investigations. It is also worth considering whether the endometrial spaces could have represented an artefact, particularly as these were not identified on preoperative imaging. However, in contrast to the case of Val-Bernal et al. (15), where a single hypoechoic space was seen on ultrasonography, the current case demonstrated innumerable 2- to 3-mm spaces within the endometrial mucosa which were likely beyond the resolution of imaging. As is normal practice in our hospital, the hysterectomy specimen was transferred to the histopathology laboratory unfixed and directly following removal making postoperative artefact highly unlikely, particularly as we have not observed similar changes in other uterine specimens. In the current case, no definite etiological factors for pneumatosis were identified and in particular the patient had no other significant medical conditions and no prior instrumentation or biopsy of the uterus. Although it is possible that the large leiomyoma led to mucosal disruption or produced obstruction of the uterine cavity thereby causing increased intralumenal pressure, the tumor did not involve the endometrium directly and the pneumatosis involved the anterior and posterior mucosal surfaces equally. It is also unclear whether the endometrial pneumatosis may have contributed towards the patient’s symptoms of menorrhagia and dyspareunia but given their duration it seems more likely that these were related to the leiomyoma. In summary, a third case of endometrial pneumatosis (emphysematous or pneumopolycystic endometritis) is presented. This curious condition appears
Int J Gynecol Pathol Vol. 33, No. 5, September 2014
self-limited clinically but the etiology remains uncertain.
REFERENCES 1. Khalil PN, Huber-Wagner S, Ladurner R, et al. Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis. Eur JMed Res 2009;14:231–9. 2. Samlaska CP, Maggio KL. Subcutaneous emphysema. Adv Dermatol 1996;11:117–51. 3. D’Cruz R, Emil S. Gastroduodenal emphysema. J Pediatr Surg 2008;43:2121–3. 4. Al-Jundi W, Shebl A. Emphysematous gastritis: case report and literature review. Int J Surg 2008;6:e63–6. 5. Grayson DE, Abbott RM, Levy AD, et al. Emphysematous infections of the abdomen and pelvis: a pictorial review. Radiographics 2002;22:543–61. 6. Sonmez G, Ozturk E, Mutlu H, et al. Education and imaging. Hepatobiliary and pancreatic: emphysematous cholecystitis. J Gastroenterol Hepatol 2007;22:2035. 7. Kvinlaug K, Kriegler S, Moser M. Emphysematous pancreatitis: a less aggressive form of infected pancreatic necrosis? Pancreas 2009;38:667–71. 8. Luaces R, Ferreras J, Patino B, et al. Pneumoparotid: a case report and review of the literature. J Oral Maxillofac Surg 2008;66:362–5. 9. Joseph RC, Amendola MA, Artze ME, et al. Genitourinary tract gas: imaging evaluation. Radiographics 1996;16:295–308. 10. Choudhury AP, Rashid M, Goddard R, et al. Pneumatosis cystoides of cervix and vagina in a patient with congestive cardiac failure. J Obstet Gynaecol 2009;29:165–7. 11. McCallion JS, Parkin DE. Emphysematous vaginitis masquerading as carcinoma of the cervix. Case report. B J Obstet Gynaecol 1988;95:309–11. 12. Mautner LS. Vaginitis emphysematosa. Can Med Assoc J 1958;80:643–7. 13. Wang Y, Topran EA, Tavassoli F. Pneuamtosis ovarii (emphysematous changes in the ovary): a case report. Int J Gynecol Pathol 2008;27:531–3. 14. Perkins MB. Pneumopolycystic endometritis. Am J Obstet Gynecol 1960;80:332–6. 15. Val-Bernal JF, Villoria F, Cagigal ML, et al. Pneumopolycystic endometritis. Am J Surg Pathol 2006;30:258–61.
