Primary Streptococcal Peritonitis
September 1, 1999 3 minutes read
Primary Streptococcal Peritonitis
Case Study
Synopsis: Streptococcus pyogenes are a rare cause of primary peritonitis that is more often found in females than in males.
A 12-year-old previously healthy, nonsexual-ly active girl recently presented to the emergency room early in the morning, several hours after she had been awakened by severe diffuse abdominal pain followed by fever and shaking chills. Examination revealed an acutely ill child with a blood pressure of 100/60 and a pulse of 120. Her abdomen was diffusely tender with evidence of rebound apparently most prominent in the right lower quadrant. Stool guaiac was negative. Her white blood count was 14,000/mm3.
She was taken to the operating room and a laparotomy was performed. Her appendix was grossly (and microscopically) normal, but purulent fluid was present, predominantly in the pelvis. No other abnormality could be detected. The patient underwent pelvic examination under general anesthesia; this was normal. Gram stain of the peritoneal fluid revealed many neutrophils and occasional gram-positive cocci. Imipenem/cilastatin was administered.
Blood and urine cultures were negative and cervical cultures grew normal flora. Peritoneal cultures, however, yielded Streptococcus pyogenes. The patient improved rapidly and was discharged on therapy with amoxicillin.
Comment by Stan Deresinski, md, facp
The intraoperative findings in this girl were puzzling until the culture results became available and solved the riddle: this previously healthy child had a rare infection, primary streptococcal peritonitis.
Primary peritonitis, infection of the peritoneal cavity in the absence of an identified intraabdominal source, is commonly seen in patients with ascites of hepatic origin, as well as children with nephrotic syndrome. Most cases are caused by Streptococcus pneumoniae or aerobic gram-negative bacilli; S. pyogenes have rarely been reported to be etiologic.
The pathogenesis of this infection is uncertain. Primary peritonitis due to aerobic gram-negative rods most likely involves direct migration of the organisms from the bowel lumen. Pneumococcal peritonitis is believed to be the result of either bacteremia or, in the case of females, migration from the genital tract. Like the pneumococcus, S. pyogenes are not a normal member of the gastrointestinal or genitourinary flora, although asymptomatic anal carriage and vaginal carriage may occur. However, infections of the gastrointestinal tract due to this organism have been reported. These include gastritis and proctitis; vaginal carriage as well as vaginal infection is reported to occur. Most cases of primary peritonitis due to this organism are reported to occur in females, potentially implicating the genital tract as the source of the organism.
Primary peritonitis due to the group A beta-hemolytic streptococcus may be severe. Several cases have been associated with the streptococcal toxic shock syndrome.
References
1. Casedevall A, et al. Primary group A streptococcal peritonitis in adults. Am J Med 1990;88:63-64.
2. Graham JC, et al. Primary group A streptococcal peritonitis. Scan J Infect Dis 1995;27:171-172.
3. Stevens DL, et al. Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A. N Engl J Med 1989;321:1-7.
4. Figuero-Colon R, et al. Group A streptococcal proctitis and vulvovaginitis in a prepubertal girl. Pediatr Infect Dis J 1984;3:439-444.
5. Watson WJ, Powers KS. Primary peritonitis associated with streptococcal toxic shock-like syndrome. Clin Pediatr (Phila) 1999;38:175-177.
6. Laroche M, Harding G. Primary and secondary peritonitis: An update. Eur J Clin Microbiol Infect Dis 1998;17:542-550.
Which of the following is correct?
a. Primary peritonitis is due to S. pyogenes occur more commonly in males than in females.
b. Most cases of primary peritonitis in patients with ascites are caused by either S. pyogenes or the pneumococcus.
c. S. pyogenes are not normal members of the gastrointestinal or genitourinary flora.
d. Primary peritonitis due to due to S. pyogenes is invariably associated with the presence of endocarditis.
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