Furthermore, the bowel was silent and abdominal compartment syndrome with a measured pressure of 25 cmH 2 O (on 8th day), developed. CT of the abdomen, on 8th day, revealed multiple peritoneal and extraperitoneal fluid collections with infectious extension to the retroperitoneum. Surgical drainage was performed; the abdomen remained open. A slow progressive recovery was followed. Closure of the abdominal walls was performed on 25th day. The patient remained in the ICU for 39 days. Serum antistreptolycin O (ASO) titer was 580 IU/ml on the 6th day (normal range, 0-180 IU/ml), rising to 2,750 IU/ml on the 21st day. Although erythema and edema of the posterior pharynx were present and the tonsils were enlarged upon admission to the ICU, swabs cultures obtained from the throat grew only commensals.He was discharged home on the 50th day on oral penicillin ( Fig. 1A). Usual laboratory findings were all in normal values. An extensive search for immunodeficiency (including assays of immunoglobulins and IgG subclasses, serum complement levels, and white cell burst) and HIV were negative. Three months later the fever and weakness reoccurred. A new abdominal CT revealed a prevesical abscess and a large abscess in the right lower abdominal quadrant. In addition, diffuse obscurity of the retroperitoneum in combination with thickening of the obturator internus muscle, possibly indicating infectious extenPrimary peritonitis caused by group A streptococci (GAS) is quite unexpected in previously healthy adults without underlying disease [1, 2,3]. Moreover, primary peritonitis due to a combination of GAS and E. coli has not been previously reported in the literature.A 40-year-old, previous healthy man, presented to an outboard clinic with 2-day history of fever 39°C, ephidrosis, and a sore throat; only antifebrile medication was prescribed. Five days later, he was admitted to a regional hospital with clinical and laboratory findings of acute peritonitis. The patient underwent urgent laparotomy. Diffuse peritonitis with a large amount of fine intra-peritoneal cloudy fluid was found; no bowel perforation was established. Broad-spectrum antibiotics (Metronidazole, netilmicin, piperacillin/tazobactam) were initiated. Two days later, the patient was led to the operating room for second time, as his condition was still unstable, requiring noradrenaline; again, no focus of infection or intestine perforation could be identified. The patient continued to deteriorate due to severe sepsis, and finally was intubated on the 4th day after the first operation, and transferred to the ICU.Upon admission to the ICU, a soft-tissue inflammation with extensive skin erythema, edema, and tenderness -with no sharply demarcated margins from the surrounding uninvolved tissue -extending to the right abdominal wall and the right thigh was evident. Although necrotizing fasciitis was considered [4], undermining of the skin was not demonstrated. Meanwhile, GAS (sensitive to penicillin) and E. coli were cultured in all peritoneal pus samples, obtained at the time...
