A 19-year-old nulliparous Chinese woman presented to the emergency room of our institution under sedation due to unconsciousness and convulsions. Her body mass index was 34.5. Her medical history was notable for a 6-month history of abnormal uterine bleeding (AUB) that persisted despite oral contraceptives use. She had no history of exposure to the AstraZeneca COVID-19 vaccine or other high-risk drugs for thrombosis. Two days prior, she was admitted to a local hospital with severe headaches, nausea, vomiting, delayed reactions, expressive aphasia, and seizures, and was diagnosed with CVT. Intravenous administration of heparin and symptomatic treatment were administered, which were ineffective. The patient continued to have seizures. Then she was transferred to our institution. A computerised tomography (CT) scan of the head demonstrated venous sinus thrombosis (Fig.
1a). Emergency cerebrovascular angiography with femoral artery and femoral vein intubation was performed. The patient received thrombolytic therapy via femoral intravenous urokinase on the same day that she presented to our institution and this was continued for 7 days. Subsequently, her general condition improved. On the 9th day of hospitalisation, the patient developed vaginal bleeding. Considering this is a common complication of thrombolytic therapy, physicians did not treat the vaginal bleeding. On the 11th day of hospitalisation, she developed massive vaginal bleeding and inspection revealed a mass protruding from the vagina. Her haemoglobin level dropped from 10.8 g/dL to 6.3 g/dL in 3 h, and a gynaecology review was requested. Physical examination revealed pallor of the skin and mucous membranes, with no signs of visceromegaly, ascites or palpable masses on abdominal examination. Gynaecologic examination revealed that the vaginal mass was approximately 17 × 15 × 10 cm, and the tissue showed local congestion, infection, and necrosis (Fig.
2). Digital vaginal examination revealed that the mass was occupied the entire vaginal cavity with a thick pedicle, and the cervix was not visible or palpable. Rectal examination revealed no tumour effects. A cervical tumour was suspected. After a brief discussion of all therapeutic options within our clinical team, and given the patient’s poor general condition and acute cerebral thrombosis,emergency transvaginal resection of the mass was performed to achieve haemostasis. The mass was removed completely from the pedicle. Postoperative pathology suggested rhabdomyosarcoma of the embryonal type (Fig.
3). The tumour pedicle was negative. Immunohistochemical results showed the following staining patterns: CD10(+), CD117(−), CD34(−), CD68(+), pan-CK(−), desmin(+), DOG1(−), Ki-67(+), LAC(−), lysozyme(−), MyoD1(+), myogenin(+), S-100(−), SAM(−), and vimentin(+). The patient was misdiagnosed with rhabdomyosarcoma of the cervix. On the 15th day after the mass resection, laparoscopy and hysterectomy were planned. Intraoperative exploration showed no uterus in the pelvic cavity. The bilateral adnexa near the uterus adhered to the scar on the pelvic floor at the vaginal vault. The visible parts of the bilateral fallopian tubes and ovaries were grossly normal. There was no palpable pelvic or para-aortic lymphadenopathy. Based on the pathology results, we believed that the mass that was removed vaginally was a completely inverted uterus. Finally, we performed laparoscopic resection of the bilateral fallopian tubes and residual cervical tissue. Postoperative pathology was negative for tumours. Finally, she was diagnosed with uterine rhabdomyosarcoma complicated by CVT and uterine inversion. Chemotherapy with radiation was recommended; however, the patient asked for adjunctive treatment to be postponed and she began her first cycle of chemotherapy 43 days after the first surgery. The patient was treated with chemotherapy consisting of vincristine, actinomycin D and cyclophosphamide (VAC). Seventy-two days after the first surgery, she developed recurrence of a 5 cm mass in the pelvis (Fig.
1b).The mass continued to grow despite further chemotherapy cycles, and during her fourth cycle of chemotherapy, pelvic magnetic resonance imaging (MRI) revealed a rapid increase in the size of the mass to 16 cm (Fig.
1c), and a chest CT scan revealed multiple metastatic nodules in both lungs(Fig.
1d). The patient continued to experience vaginal bleeding and received multiple blood transfusions. The tumor occupied the pelvic cavity and caused urethral obstruction. As the patient experienced tumour progression despite chemotherapy, she was started on palliative treatment and died in less than 6 months.