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.