Primary Peritonitis Due to Streptococcus pyogenes

Abstract

Introduction Primary peritonitis (PP) is peritonitis occurring in patients without underlying causes such as perforated viscus, preexisting ascites, or nephrosis. We report 2 cases of primary Streptococcus pyogenes peritonitis and review the literature on this subject since January 1, 2000. Case Reports Patient 1 was a 45-year-old woman who presented to hospital with fever, diarrhea, and abdominal pain. Examination revealed fever, hypotension, epigastric tenderness, and guarding. Computed tomography (CT) scan was negative for signs of perforated viscus. Workup included blood cultures, parenteral antibiotics, and surgical consult. She underwent emergent operative intervention, which revealed generalized peritonitis, cloudy peritoneal fluid, and no evidence of perforated viscus. Blood cultures revealed S. pyogenes. She underwent an unremarkable recovery on parenteral ceftriaxone followed by oral ampicillin. Patient 2 was a 47-year-old woman who presented to hospital with fever, chills, anorexia, nausea, vomiting, and abdominal pain. Physical examination showed fever, hypotension, tachycardia, and diffuse abdominal tenderness but no rebound tenderness. Abdominal CT scan revealed fluid but no free air. Paracentesis revealed purulent fluid, which on Gram-stained smear showed gram-positive cocci in pairs and chains. Blood and peritoneal fluid cultures were positive for S. pyogenes. Exploratory laparotomy by surgical consultant showed purulent fluid and fibrinous exudate with multiple interloop abscesses and no perforated viscus. Postoperatively, she received parenteral penicillin G, transient hemodialysis, and ventilator support with eventual full recovery. Review of Literature We reviewed the medical literature from January 1, 2000, to December 31, 2016, and found 36 patients with diagnosis of S. pyogenes PP. Despite most of these case reports stating that the occurrence of S. pyogenes PP is “rare,” it seems that it is more common than previously thought. All but 3 patients underwent surgical intervention. All 38 patients presented with physical findings of an acute abdomen. There was no evidence of free air on CT scanning or ultrasound of the 33 patients who underwent one of these imaging techniques. Septic shock was common, and all but 1 patient survived. Conclusions Streptococcus pyogenes PP is more common than previously reported, is associated with physical findings of acute abdomen, is usually accompanied by circulatory shock, and is almost always clinically responsive to treatment with operative and antimicrobial agent interventions.

Primary Peritonitis: An Index Case of Mycoplasma hominis Infection in a Healthy Female

“…Again, the majority of patients underwent exploratory surgery (92.1%). They conclude GAS peritonitis may not be as rare as previously suspected [3]. …”

“…Standard analysis of blood, peritoneal fluid, and peritoneal biopsy cultures was unable to detect this organism. In contrast, other recognized causes of primary peritonitis in healthy women, such as Streptococcus pneumoniae and Group A Streptococcus, typically have positive cultures, making organism identification more straightforward [1–3]. …”

“…Streptococcus pneumoniae has been described as a cause of primary peritonitis, especially in the pediatric population [3, 7, 8]. These patients typically present with an acute abdomen, and surgery is often pursued for presumed secondary peritonitis.…”

“…There are numerous case reports of Group A Streptococcus (GAS) and Streptococcus pneumoniae causing primary peritonitis in young previously healthy individuals [1–3]. Primary peritonitis with Mycoplasma hominis has been described in the renal transplant population [4–6]; however, there is no known reported case of primary peritonitis caused by Mycoplasma hominis in a healthy nonimmunocompromised adult.…”