Management of Primary Group A Streptococcal Peritonitis: A Systematic Review

[A rare cause of acute abdomen in a young immunocompetent woman]

Streptococcus pyogenes is a human pathogenic, gram positive bacterium that primarily leads to pharyngitis or soft tissue infections. Primary peritonitis caused by S. pyogenes infection is rare and there are only a few published cases worldwide. Primary peritonitis due to other pathogens occurs in immunosuppressed conditions such as HIV or other chronic diseases. However, younger, healthy women are more likely to be affected by S. pyogenes peritonitis. At present, the underlying molecular mechanisms can only be speculated on. One possibility is that, similar to the clinical picture of streptococcal toxic shock syndrome (STSS), a specific serotype of the M protein in combination with inhibition of the cell response of neutrophil granulocytes could play a role. In addition to peritonitis, the clinical picture may include other organ manifestations such as acute kidney damage or circulatory dysregulation. In terms of treatment, rapid pathogen-directed empirical antibiotic therapy is the treatment of choice. If there is no indication of secondary peritonitis, diagnostic laparoscopy can be dispensed with in the further diagnostic work-up.

Primary Peritonitis Due to Group A Streptococcus Successfully Treated with Intraperitoneal Drainage

A 42-year-old woman was admitted to our hospital because of lower abdominal pain and diarrhea. Although the initial symptoms and imaging findings were similar to those of acute enteritis, blood and ascites cultures led to the diagnosis of primary peritonitis caused by group A Streptococcus. In many cases, the disease rapidly deteriorates, and laparotomy is performed for the early diagnosis and to reduce the number of bacteria in the abdominal cavity. In the present case, intraperitoneal drainage was effective for avoiding surgery. We suggest that intraperitoneal drainage is effective for the treatment of this disease.

Group A Streptococcus Primary Peritonitis in Children, New Zealand

Group A Streptococcus (GAS) primary peritonitis is a rare cause of pediatric acute abdomen (sudden onset of severe abdominal pain); only 26 pediatric cases have been reported in the English language literature since 1980. We discuss 20 additional cases of pediatric primary peritonitis caused by GAS among patients at Starship Children's Hospital, Auckland, New Zealand, during 2010-2022. We compare identified cases of GAS primary peritonitis to cases described in the existing pediatric literature. As rates of rates of invasive GAS increase globally, clinicians should be aware of this cause of unexplained pediatric acute abdomen.

Streptococcus pyogenes Infection-Induced Primary Peritonitis in a Healthy Adult Female: A Very Rare Causative Agent

A 44-year-old woman with an unremarkable medical history presented to another hospital complaining of lower abdominal pain and nausea. The clinical presentation was consistent with an acute abdomen, raising suspicion of gastrointestinal tract perforation. However, imaging studies failed to provide evidence of perforation. Subsequently, the patient was diagnosed with peritonitis of unknown origin and promptly administered broad-spectrum antibiotics in a fasting state. Although the patient initially exhibited unstable symptoms, hemodynamics, and serology, she gradually improved over three days, with values approaching normal levels. On the sixth day of hospitalization, a follow-up abdominal computed tomography scan revealed pleural effusions, extensive ascites, and intra-abdominal stranding. The thickened wall of the small intestine and intra-abdominal stranding that were suggestive of peritonitis were further exacerbated. On the seventh day of hospitalization, aerobic and anaerobic blood cultures revealed the presence of Gram-positive cocci, later confirmed to be Streptococcus pyogenes, leading to the diagnosis of S. pyogenes infection-induced primary peritonitis. The source of infection was identified as a 10 mm hydrosalpinx in the left fallopian tube, suggesting the possibility of retrograde infection. The patient ultimately made a complete recovery without relapse and has been doing well since. This case report highlights a unique and rare occurrence of primary peritonitis caused by group A Streptococcus associated with infection from a hydrosalpinx in an otherwise healthy and young female patient. The diagnosis of primary spontaneous bacterial peritonitis in such an individual presents an uncommon clinical manifestation, emphasizing the importance of considering atypical sources of peritoneal infection in clinical practice.

Acute abdomen: a rare presentation of group a streptococcal infection

In this case report we describe a 38-year old female patient admitted to the emergency department with acute abdomen and sepsis. Broad-spectrum antibiotics were started. Abdominal imaging was inconclusive, exploratory laparoscopy showed four-quadrant peritonitis. No provoking factor could be withheld. Due to clinical deterioration the patient was transferred to the intensive care unit. Blood cultures showed the presence of group A streptococcus, and clindamycin was associated. She recovered, and could be discharged after several days. Peritonitis caused by group A Streptococcus pyogenes is rare in healthy individuals, and occurs mostly in middle-aged women. There is no consensus regarding surgical treatment but surgical exploration is often necessary to exclude secondary peritonitis. Treatment with broad-spectrum antibiotics and supportive measurements remain the cornerstone in patient management. Association of clindamycin has been shown to reduce mortality. There is inconclusive evidence to support Intravenous polyspecific immunoglobulin G (IVIG) therapy in streptococcal toxic shock syndrome.

Peritonitis caused by group A streptococcus: A case report and literature review

BACKGROUND

Group A streptococcus (GAS) occasionally causes life-threatening infections. We encountered a case of GAS peritonitis associated with bilateral salpingitis.

CASE PRESENTATION

A 56-year-old previously healthy woman suddenly experienced a fever of 40 °C and lower abdominal pain, and was taken to the emergency room. She exhibited a condition of severe sepsis with pan-peritonitis. Although an intra-peritoneal source of infection was not detected preoperatively, an exploratory laparotomy was performed at 3 h after her arrival. During the surgery, bilateral salpingitis was observed. Peritoneal drainage was performed. Meropenem was administered and she was extubated on the next day. GAS was detected in the vaginal fluid culture and ascitic fluid culture. Antibiotics therapy was completed on postoperative day 9 and the patient was discharged on day 10 without any complications.

METHODS

A literature review was performed using the following algorithm: "(group A streptococcus OR streptococcus pyogenes) AND (peritonitis)". All case reports and case series published in English after 1990 were reviewed.

RESULTS

Fifty-six reports including 65 cases were eligible. There was a strong sex difference, with 80% of cases being female. All patients had symptoms of peritonitis, 80% had high-grade fever, and 74% had shock. The average time from onset to start of treatment was 3.8 days. Abdominal surgeries were required in 80% of cases. Multiple organ failure developed in 23%, and the mortality rate was 4.6%.

DISCUSSION

GAS peritonitis is a rare but life-threatening disease. Emergency surgical exploration and drainage are required to prevent progression to multiple organ failure.

Acute fatal group A Streptococcal primary peritonitis following vaginal delivery

Acute primary peritonitis due to group A streptococci (GAS) is a rare but life-threatening disease most often seen in case of liver cirrhosis or nephrotic syndrome. The specific mechanism of this infection remains unknown and according to the literature hematogenous, lymphatic, retrograde inoculation from the genitourinary tract and translocation of intestinal tract flora have all been proposed. We report a case of a 37-year-old previously healthy patient who presented to the emergency, four days after vaginal delivery, with abdominal pain and septic shock. Acute peritonitis was diagnosed and peritoneal and blood culture revealed group A streptococci. Unfortunately, the patient died within 12 h despite adequate resuscitation and antimicrobials. The present case report highlights the importance of an early diagnosis with an adequate therapy in case of GAS peritonitis after vaginal delivery.

Group A Streptococcal Toxic Shock-Like Syndrome in a Male Presenting as Primary Peritonitis: A Case Report and a Review in Japan

BACKGROUND

Streptococcal toxic shock-like syndrome (TSLS) is a severe infection caused by group A hemolytic streptococcus. It is clinically characterized by rapidly progressive septic shock and multiple organ failure within just a few hours. TSLS presenting as primary peritonitis is rare, especially in a male. Herein, we report a case of TSLS in a male presenting with primary peritonitis, with a review of 25 cases in Japan.

CASE PRESENTATION

A 51-year-old male was referred to our hospital with abdominal pain and hypotension. We made a preoperative diagnosis of peritonitis with septic shock and performed an emergency operation. Intraoperative findings indicated no marked origin of the peritonitis. Preoperative blood culture showed the presence of group A hemolytic streptococcus. The patient required intensive care involving artificial respiration, abdominal drainage and cytokine absorption therapy, and was discharged on postoperative day 25.

CONCLUSION

TSLS in a male presenting as primary peritonitis is rare. Although this condition is a severe infection, it can be treated by multimodal therapy.

Streptococcus pyogenes peritonitis: a rare, lethal imitator of appendicitis

Streptococcus pyogenes is a common cause of infection. Since 2010, the Centers for Disease Control has noted a 24% rise in invasive S. pyogenes infections with a mortality rate of 10%. We present a case series and review of the English literature. Two patients presented with findings concerning for appendicitis, each underwent laparoscopic appendectomies. Both had diffuse peritoneal inflammation without appendicitis, cultures grew S. pyogenes and both recovered with appropriate antibiotics. Thirty cases were identified in a review of the English literature. The average age was 27 years, 75% were in women, 9% were immunocompromised, 15% had rashes and 88% underwent surgical intervention. Previous work identified female gender, immunosuppression and preceding varicella infection as risk factors for invasive S. pyogenes. Given the similarities to appendicitis, early suspicion can influence antibiotic therapy and possibly improve outcomes.

Group A streptococcal pharyngitis associated with primary peritonitis

Primary peritonitis, a bacterial infection within the peritoneal cavity that arises in the absence of an intraperitoneal source, is a rare entity in paediatrics. We describe the case of a previously healthy 11-year-old girl who presented with an acute abdomen and was found to have primary peritonitis due to Streptococcus pyogenes She had an episode of pharyngitis with pharyngeal cultures positive for S. pyogenes in the month prior to presentation. We performed a review of the literature to better elucidate the risk factors, pathophysiology and presentation of peritonitis due to S. pyogenes and to draw attention to the potential association between group A streptococcal pharyngitis and peritonitis.

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.

Necrotizing fasciitis following primary peritonitis caused by Streptococcus pyogenes with covS mutation in a healthy woman: a case report

Background

Primary peritonitis due to Streptococcus pyogenes (S. pyogenes) is uncommon in patients without comorbid conditions such as immunosuppression, nephritic disease, or liver cirrhosis. Furthermore, it does not cause another infection at the same time in a healthy person. However, several S. pyogenes mutants have been reported, and some of them exhibit strong virulence. Mutation of the control of virulence (cov) S gene of Streptococcus enhances bacterium survival by repressing negative regulators of virulence, which causes bacterial invasion of aseptic tissues, such as the parenteral space. We report a case of primary peritonitis and subsequent necrotizing fasciitis by the same S. pyogenes species with mutated covS in a previously healthy woman.

Case presentation

We present the case of a 55-year-old woman admitted to the hospital due to abdominal pain and nausea. She was treated for peritonitis. A few days later, she became hypotensive and tachycardic and was transferred to the intensive care unit (ICU) for the treatment of septic shock with primary peritonitis. On the second day of her ICU stay, both of her forearms developed swelling and redness around the peripheral injection site. The patient had developed necrotizing fasciitis. Since her skin symptoms spread rapidly, urgent debridement was performed. Her condition improved with antibiotic treatment and multiple episodes of debridement. S. pyogenes was detected in cultures of the patient’s blood, ascites, and skin. The identified strain was emm89 genotype and had a genetic mutation of covS.

Conclusions

S. pyogenes with covS mutation may spread from a portal, such as the upper respiratory tract or digestive system, to all organs immediately, causing septic shock. Infection with S. pyogenes with mutated genes should be considered in the differential diagnosis of gastrointestinal symptoms, even in a previously healthy patient.

Streptococcus pyogenes primary peritonitis

Streptococcus pyogenes, a Gram-positive bacterium, is a rare cause of primary peritonitis. Diagnosed on imaging and with positive growth in blood cultures, a case of primary peritonitis caused by S. pyogenes is discussed here, with a brief literature review, and used to discuss several key principles of antibiotic use, including selection of antibiotic, investigations and non-pharmacological management of infection.

Streptococcal Toxic Shock Syndrome: Life Saving Role of Peritoneal Lavage and Drainage

PURPOSE

We encountered a case where an infection with group A streptococcus (GAS; ie, Streptococcus pyogenes) initially caused primary peritonitis and then subsequently caused streptococcal toxic shock syndrome. The patient’s life was likely saved by an emergency laparotomy followed by extensive peritoneal lavage and drainage.

CASE PRESENTATION

A 40-year-old woman was admitted to the Emergency Department for lower abdominal pain and numbness in the extremities. She presented with systemic inflammatory response syndrome. An emergency laparotomy was performed, and ascites that resembled pus and general peritonitis were noted. Peritoneal lavage and drainage were performed, and GAS was isolated from peritoneal fluid. Gram staining of cervical polyp specimens revealed Gram-positive bacteria.

CONCLUSIONS

The patient was diagnosed with streptococcal toxic shock syndrome due to an ascending GAS infection originating from vagina.

Primary peritonitis by Streptococcus pyogenes. A condition as rare as it is aggressive

We report the case of a 60-year-old female patient who presented to the emergency room for abdominal pain standing with impaired general status, fever of up to 38.7ºC, and somnolence. Upon arrival the patient had a heart rate of 115 bpm, hypotension (80/40 mmHg),acute respiratory distress, and both hepatic and renal failure. During her examination the patient was drowsy and had a diffusely tender abdomen with peritoneal irritation signs. Blood tests revealed 22,000 WBCs (82%N), CRP 32.4 mg/dL, total bilirubin 3.2 mg/dL, GOT 300 U/L, GPT 160 U/L, LDH 200 U/L, AP 310 U/L, 91,000 platelets, creatinine2.3 mg/dL, and PA 64%. An abdominal CT scan was performed, which revealed a minimal amount of free intraperitoneal fluid with no other findings. Given the patient's poor status an exploratory laparoscopy was carried out, which found a moderate amount of diffuse purulent exudate, particularly in interloop and lesser pelvis areas, with no additional findings. Following surgery she was transferred to the intensive care unit on wide spectrum antibiotics .Peritoneal exudate cultures from the surgical procedure revealed Streptococcus pyogenes. The patient had a favorable outcome being subsequently discharged from hospital at day 10 after the procedure. S. pyogenesis a beta hemolytic streptococcus well known as a cause of pharyngotonsillar, skin and soft tissues infection. Primary peritonitis by S.pyogenesis a rare condition with only a few isolated cases reported. PP cases by S.pyogenes predominantly involve previously healthy young women. PP diagnosis is usually retrospective, when other causes have been ruled out by surgery and culture is positive post hoc. An appropriate differential diagnosis from conditions such as gram-negative shock, staphylococcal toxic shock, meningococcal disease, viral infection, etc., is crucial. Abdominal CT may be helpful but a variable amount of free intraperitoneal fluid is usually the only finding. The surgical approach is usually laparoscopy in experienced sites. Attentive monitoring at an intensive care unit and adequate antibiotic therapy are key in association with surgery. There is no clear consensus on the antibiotics to be used for severe infection with S.pyogenes; empirical amoxicillin-clavulanic is usually the initial choice, followed after microbiological confirmation by clindamycin and a third-generation cephalosporin.

Acute abdomen due to group A streptococcus bacteremia caused by an isolate with a mutation in the csrS gene

Streptococcus pyogenes (group A streptococcus) is an aerobic gram-positive coccus that causes infections ranging from non-invasive pharyngitis to severely invasive necrotizing fasciitis. Mutations in csrS/csrR and rgg, negative regulator genes of group A streptococcus, are crucial factors in the pathogenesis of streptococcal toxic shock syndrome, which is a severe, invasive infection characterized by sudden onset of shock and multiorgan failure, resulting in a high mortality rate. Here we present a case of group A streptococcal bacteremia in a 28-year-old Japanese woman with no relevant previous medical history. The patient developed progressive abdominal symptoms that may have been due to spontaneous bacterial peritonitis, followed by a state of shock, which did not fulfill the proposed criteria for streptococcal toxic shock. The isolate was found to harbor a mutation in the negative regulator csrS gene, whereas the csrR and rgg genes were intact. It was noteworthy that this strain carrying a csrS mutation had caused group A streptococcal bacteremia characterized by acute abdomen as the presenting symptom in a young individual who had been previously healthy. This case indicates that group A streptococcus with csrS mutations has potential virulence factors that are associated with the onset of group A streptococcal bacteremia that does not meet the diagnostic criteria for streptococcal toxic shock syndrome.

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.

Intra-abdominal sepsis--epidemiology, aetiology and management

Peritonitis is a progressive disease leading inexorably from local peritoneal irritation to overwhelming sepsis and death unless this trajectory is interrupted by timely and effective therapy. In children peritonitis is usually secondary to intraperitoneal disease, the nature of which varies around the world. In rich countries, appendicitis is the principal cause whilst in poor countries diseases such as typhoid must be considered in the differential diagnosis. Where resources are limited, the clinical diagnosis of peritonitis mandates laparotomy for diagnosis and source control. In regions with unlimited resources, radiological investigation, ultrasound, CT scan or MRI may be used to select patients for non-operative management. For patients with appendicitis, laparoscopic surgery has achieved results comparable to open operation; however, in many centres open operation remains the standard. In complicated peritonitis "damage control surgery" may be appropriate wherein source control is undertaken as an emergency with definitive repair or reconstruction awaiting improvement in the patient's general condition. Awareness of abdominal compartment syndrome is essential. Primary peritonitis in rich countries is seen in high-risk groups, such as steroid-dependent nephrotic syndrome patients, whilst in poor countries the at-risk population is less well defined and the diagnosis is often made at surgery.

Myrsine seguinii ethanolic extract and its active component quercetin inhibit macrophage activation and peritonitis induced by LPS by targeting to Syk/Src/IRAK-1

ETHNOPHARMACOLOGICAL RELEVANCE

Myrsine seguinii H. LÉVEILLÉ (syn. Rapanea neriifolia) (Myrsinaceae) is a medicinal plants traditionally used in Myanmar to treat infectious and inflammatory diseases. Since none of reports have systematically demonstrated the anti-inflammatory activity of this plant, we aimed to mechanistically understand the regulatory roles of the plant in inflammatory responses using the ethanolic extract of Myrsine seguinii (Ms-EE).

MATERIALS AND METHODS

Activated macrophages and peritonitis symptoms induced by lipopolysaccharide (LPS) were employed. HPLC analysis was used to identify active components. To characterize direct target enzymes, kinase assay was established.

RESULTS

Ms-EE inhibited the production of nitric oxide (NO) and prostaglandin (PG)E2 in RAW264.7 cells and peritoneal macrophages stimulated by LPS. This extract suppressed the mRNA expression of the inducible NO synthase (iNOS) and cyclooxygenase (COX)-2 genes by down-regulating the activation of nuclear factor (NF)-κB and activator protein (AP-1). Interestingly, it was found that Ms-EE can directly suppress the enzyme activities of Syk, Src, and interleukin-1 receptor-associated kinase-1 (IRAK-1). Similarly, orally administered Ms-EE inhibited the phosphorylation of Src and Syk in peritoneal exudate-derived cells prepared from peritonitis. Finally, HPLC analysis clearly demonstrated that quercetin is a major active component with suppressing activity on the release of inflammatory mediators (NO and PGE2), and the enzyme activities of Src, Syk, and IRAK-1.

CONCLUSION

Ms-EE containing quercetin negatively modulates macrophage-mediated in vitro inflammatory responses and LPS-induced peritonitis by blocking the Src/Syk/NF-κB and IRAK-1/AP-1 pathways, which contributes to its major ethnopharmacological use as an anti-inflammatory herbal medicine.