Primary pneumococcal peritonitis in pregnancy

Abstract

To the Editors,We report a case of primary pneumococcal peritonitis in a previously healthy pregnant woman without identifiable source of infection. A 22-year-old nullipara presented at 24-weeks gestation with a 1-day history of severe abdominal pain and nausea. She had no other pertinent illness and denied illicit drug or alcohol use. A test for HIV had been negative during the pregnancy. Her oral temperature was 38.18C. She had diffuse abdominal tenderness with rebound and guarding. Bowel sounds were absent. The physical examination was otherwise unremarkable. The laboratory workup was significant for leukocytosis (39200/ml) and an elevated C -reactive protein of 42.7 mg/dl (normal range 50.5 mg/dl). Ultrasonographic examination showed an appropriate for gestational age fetus with normal amniotic fluid volume and flow indices in the umbilical and middle cerebral arteries. Diagnostic laparoscopy revealed a moderate amount of purulent fluid in the abdominal cavity. Appendix, ovaries, Fallopian tubes, gall bladder, and all intraperitoneal segments of small and large intestines appeared unremarkable except for mild inflammatory changes. Cultures were taken and the abdomen irrigated thoroughly with normal saline. Antibiotic treatment with cefuroxime and metronidazole was initiated, and the patient's condition improved rapidly. The intraperitoneal cultures grew Streptococcus pneumonia. Vaginal and cervical swabs revealed only physiological flora, blood and urine cultures were negative. A transthoracic echocardiogram to rule out endocarditis and a thorough examination of the patient's upper respiratory tract were performed without any evidence of infection. Pharyngeal cultures taken 3 days after the initiation of antibiotic therapy were also negative. As

Primary pneumococcal peritonitis can be the first presentation of a familial complement factor I deficiency1

“…It is currently thought to represent three distinct clinical groups: (a) pneumococcal peritonitis associated with liver disease, infectious hepatitis, cirrhosis, ascites, nephrotic syndrome, chronic renal failure and continuous ambulatory peritoneal dialysis, autoimmune disease or known immunocompromise including HIV [11], (b) pneumococcal peritonitis associated with gastrointestinal disease including appendicitis or after intra‐abdominal surgery [12] and (c) pneumococcal peritonitis sometimes, but not always, presenting with an apparent genitourinary focus in otherwise healthy young women. We identified 40 published descriptions of the latter [13–17]. The fact that the disease is more common among women is thought to represent an infection source from the female genital tract or an ascending infection from the vagina: the latter is also supported by the fact that 13 of 40 women had an intrauterine contraceptive device (IUCD) in place, five of 40 were pregnant or postpartum and at least seven of 40 had a clinical diagnosis of pelvic inflammatory disease.…”