Fulminant group A streptococcal infections. Report of two cases

Streptococcus pneumoniae primary peritonitis mimicking acute appendicitis in an immunocompetent patient: a case report and review of the literature

Introduction

Primary peritonitis without an identifiable intra-abdominal source is extremely rare in healthy individuals; it is commonly seen in cases of nephrotic syndrome, cirrhosis and end-stage liver disease, ascites, immunosuppression, and inflamed peritoneum due to pre-existing autoimmune and oncological conditions.

Case presentation

We present the case of a 68-year-old Caucasian woman operated on due to acute abdomen with a provisional diagnosis of acute appendicitis. During the operation a small amount of free intra-abdominal fluid was found. Her uterus, ovaries, and fallopian tubes were macroscopically normal. Therefore, with the suspicion of appendicitis, appendectomy was performed. Her blood cultures were negative while peritoneal fluid was positive for capsulated form of Streptococcus pneumoniae. A 30-day follow-up was performed and she was asymptomatic without any sign of infection.

Discussion

Streptococcus pneumoniae commonly causes upper respiratory tract infection and cutaneous infections. It very rarely causes gastrointestinal infection and it is very rarely responsible for primary peritonitis and septic shock syndrome.

Conclusion

Pneumococcal peritonitis has a rare occurrence and represents a clinical challenge because of its subtle and non-specific clinical findings. The interest in our case lays in the relatively rare diagnosis of primary peritonitis mimicking acute appendicitis.

Treatment with antibodies against primary group A streptococcal peritonitis: A case report and a review of the literature

RATIONALE

Several reports describe severe group A streptococcal (GAS) infections causing septic shock, soft-tissue necrosis, and multiple organ failure known as streptococcal toxic shock syndrome (STSS). However, primary peritonitis with GAS is rare and most of them were undertaken surgical procedure.

PATIENT CONCERNS

We herein reported the case of 26-year-old healthy woman with sudden severe abdominal pain and hypotension. Computed tomography (CT) showed that large amount of free fluid in the peritoneal cavity consist with peritonitis, and no free air.

DIAGNOSES

Primary peritonitis with GAS.

INTERVENTIONS

Proper antibiotic therapy according to blood culture results.

OUTCOMES

After antibiotic therapy, the patient recovered well without complications.

LESSONS

An appropriate diagnostic approach and prompt antibiotic therapy is essential in GAS primary peritonitis.

Group A Streptococcal Peritonitis and Toxic Shock Syndrome in a Postmenopausal Woman

We herein report the case of a 66-year-old woman presenting with symptoms of gastroenteritis. Computed tomography showed small-bowel dilation without ischemic signs. After admission, she went into shock and was treated for sepsis of unknown origin. She was later diagnosed with group A streptococcal peritonitis due to an ascending vaginal infection. This case highlights the importance of considering Group A Streptococcus (GAS) infection as a cause of peritonitis in postmenopausal women.

Group A Streptococci: A rare and often misdiagnosed cause of spontaneous bacterial peritonitis in adults

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We present three different and well-described cases of severe GAS peritonitis.

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We give a review of current literature.

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We highlight the difficulties in treatment and diagnostics.

Introduction

Acute primary peritonitis due to group A Streptococci (GAS) is a rare but life-threatening infection. Unlike other forms of primary peritonitis it affects predominantly young previously healthy individuals and thus is often confused with the more frequent secondary peritonitis. A case series of three patients is presented as well as a review of the literature focusing on pitfalls in the diagnose and therapy of GAS peritonitis.

Methods

A retrospective analysis of three patients with primary GAS peritonitis was performed. Furthermore a systematic review of all cases of primary GAS peritonitis published from 1990 to 2013 was performed comparing demographics and clinical presentation, as well as radiological imaging, treatment and outcome.

Results

All three female patients presented initially with high fever, nausea and severe abdominal pain. Radiological imaging revealed intraperitoneal fluid collections of various degrees, but no underlying cause of peritonitis. Broad antibiotic treatment was started and surgical exploration was performed for acute abdomen in all three cases. Intraoperatively fibrinous peritonitis was observed, but the correct diagnosis was not made until microbiological analysis confirmed GAS peritonitis. One patient died within 24 h after admission. The other two patients recovered after multiple surgeries and several weeks on the intensive care unit due to multiple organ dysfunction syndrome. The fulminant clinical course of the three patients resembled those of many of the published cases: flu-like symptoms, high fever, severe acute abdominal pain and fibrinous peritonitis without obvious infectious focus were the most common symptoms reported in the literature.

Conclusion

GAS primary peritonitis should be considered in particular in young, previously healthy women who present with peritonitis but lack radiological findings of an infectious focus. The treatment of choice is immediate antibiotic therapy. Surgical intervention is difficult to avoid, since the diagnosis of GAS peritonitis is usually not confirmed until other causes of secondary peritonitis have been excluded.

A Rare Case of Primary Group A Streptococcal Peritonitis

Primary Group A streptococcal peritonitis is a rare clinical entity that is almost always associated with underlying disease. Group A streptococcus commonly causes upper respiratory tract infections and cutaneous infections such as impetigo and erysipelas. However, Group A streptococcus has rarely been associated with gastrointestinal infections. This is a case report describing a previously healthy adult male who developed primary Group A streptococcal peritonitis. Diagnostic laparoscopy resulted in identification of peritonitis without an identifiable intra-abdominal source. Appropriate antibiotic therapy was instituted. Culture of blood, sputum, urine, and urethra were all pathogen free. The patient made a complete recovery and was dismissed from the hospital on oral clindamycin and cephalexin. To the best of our knowledge this report represents the only documented case of primary Group A streptococcal peritonitis in a male patient without any significant past medical history.

Primary peritonitis due to group A streptococcus

Primary peritonitis is a rare condition occurring, by definition, in patients without underlying causes, such as perforated viscus, pre-existing ascites, or nephrosis. We report a case of primary peritonitis and shock due to group A beta-hemolytic streptococcus, a rare etiology. A review of the world's literature shows a predilection for women to have this condition. The entry site is obscure in most cases. Asymptomatic genital tract colonization may be a portal of entry in some women. Shock or toxic shock syndrome often accompany the abdominal findings. Laparotomy to exclude a perforated viscus may be unavoidable. Despite the significant morbidity, expeditious and appropriate antibiotic therapy is curative.

A clinical study of beta-haemolytic groups A, B, C and G streptococcal bacteremia in adults over an 8-year period

All of the 88 episodes of beta-haemolytic streptococcal bacteremia (2.9% of all bacteremias) in adult patients during the years 1987-94 in a university hospital were reviewed. 38 bacteremias (43%) were caused by group A, 24 (27%) by group B, 3 (4%) by group C, and 23 (26%) by group G beta-haemolytic streptococcal. There was a statistically significant increase in group A and decrease in group C and G bacteremias (p < 0.02) compared to an earlier 8-year period in the same hospital, although the total number of streptococcal bacteremias remained the same. The most common T types of group A streptococcal strains were T11 (26%), T28 (14%), T6 and T1 (11% each), and T12 (8%). Cardiovascular disease, skin lesions, malignancy, and alcohol abuse were the most common underlying conditions. The most usual types of infection were skin (47%) and respiratory tract infections (23%). The overall mortality was 16%. It was highest in group A (24%) and lowest in group C (0%), 38% of patients with pneumonia died. All streptococcal strains were sensitive to penicillin, vancomycin, and cephalosporins. 11% of group A and 12% of all the strains had decreased sensitivity to erythromycin, 14 and 38% to tetracycline, and 0 and 2% to clindamycin, respectively.

Streptococcal toxic shock syndrome in a postpartum woman. Case report and review of the literature

A case of streptococcal toxic shock syndrome in a 29-year-old postpartum woman is described. The patient presented with hypotension, coagulation defects, adult respiratory distress syndrome and scarlet exanthema as a complication of hemolytic group A streptococcal endometritis. One hundred and twenty-two other cases of streptococcal toxic shock syndrome in the literature are reviewed and the criteria of the syndrome discussed. Streptococcal toxic shock syndrome seems to be increasing along with more frequent invasive streptococcal infections in several countries. It is therefore important to recognize and treat the infection as early as possible to minimize the risk of mortality.

Primary group A streptococcal peritonitis

Primary peritonitis caused by Group A beta-haemolytic streptococci (GAS) is extremely rare and is usually only seen in the presence of underlying disease. This report describes the case of a previously fit young woman who developed primary GAS peritonitis. She had a laparotomy performed at which large amounts of intra-peritoneal pus was identified but no focus of infection was found. Broad spectrum antibiotics were initially used, these were changed to intravenous benzylpenicillin when GAS was isolated. She made a good recovery and was discharged 2 weeks after admission on oral amoxycillin. The organism was serotyped as T3/M3/R3 (opacity factor negative) and it is interesting that the same serotype was isolated from a throat swab taken from her daughter. We also discuss the possible routes of infection and the epidemiology of invasive GAS disease.

Streptococcal toxic shock-like syndrome. The importance of surgical intervention

Pyrogenic exotoxins A, B, and C produced by group A beta-hemolytic streptococci (Streptococcus pyogenes) may cause a syndrome characterized by fever, rash, desquamation, hypotension, and multi-organ-system dysfunction. This syndrome, the streptococcal toxic shock-like syndrome (TSLS), has a rapid and fulminant course closely resembling the staphylococcal toxic shock syndrome (TSS) caused by the staphylococcal toxic shock syndrome toxin-1 (TSST-1). The recent recognition of this syndrome is thought to stem from the appearance of more virulent strains of streptococci that have a greater tendency to produce potent exotoxins than prior strains. During the past 6 years, the authors have treated six patients with TSLS; three of these patients have presented recently. The sites of streptococcal infection associated with the development of the syndrome are frequently in soft tissue and skin. Early diagnosis, treatment with penicillin, and radical operative debridement are required.