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\begin{document}

\title{Acute primary peritonitis due to group A Streptococci: An unusual cause
of peritonitis following vaginal delivery}



\author[1]{Mohamed Aziz Daghmouri}%
\author[2]{Fatma Zahra  Affes }%
\author[2]{Alia  Jebri }%
\author[2]{Raja  Boussassi}%
\author[2]{Sonia Ben Hamouda}%
\author[2]{Badreddine  Bouguerra}%
\author[2]{Mohamed Houissa}%
\affil[1]{Charles Nicolle Hospital}%
\affil[2]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 05, 2024}


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\textbf{Keywords}

Group A streptococcus, primary peritonitis, streptococcal toxic
syndrome, vaginal delivery

\textbf{Introduction}

Group A streptococcus (GAS), also known as streptococcus pyogenes,
causes mild infections, the most frequently observed ones are
pharyngitis and impetigo in addition to necrotizing fasciitis. However,
the incidence of GAS infection is increasing according to several
studies and their presentation are becoming more severe (1,2).
Streptococcal toxic syndrome which is considered as a rare and dramatic
manifestation of GAS infection, could be presented as primary
peritonitis in previous healthy patient complicated by a septic shock
with multiple organ failure (3). So we present a rare case of an unusual
acute primary peritonitis due to GAS following vaginal delivery in a
previous healthy patient aged of 37-year-old, in order to highlight the
importance of an early good diagnostic in addition to the initiation of
an adequate therapy on time with the aim to improve the prognosis which
is dark most of the times.

\textbf{Case presentation}

A 37-year-old patient (Parity 3, Gestation 2), without medical history,
was admitted four days after vaginal delivery which was spontaneous with
lateral episiotomy. It was twin pregnancy. Serologic testing of HIV and
hepatitis in addition to vaginal swabs and urine culture were done
during pregnancy and were negative. Immediate post-partum period was
uneventful and she was discharged after 24 hours.

At admittance, she presented an unspecific abdominal pain with septic
shock. Axillary temperature was 36\selectlanguage{ngerman}°C. Blood pressure was 80/30 mmHg and
she had tachycardia 130/min in addition to marbling and cold limbs.
Abdominal ultrasound revealed free intra-abdominal fluid. Fluid
resuscitation was started rapidly in addition to the use of
catecholamine (The dose of noradrenaline used was from 0.5 \selectlanguage{greek}µ\selectlanguage{english}g/kg/min to
a maximum of 2 \selectlanguage{greek}µ\selectlanguage{english}g/kg/min). She was tachypneic with a respiratory rate of
30 cycle/min. An unspecific bowel infection was suspected and
broad-spectrum antibiotic treatment with imipenem 1g, amikacin 20 mg/kg
and teicoplanin 400 mg was initiated. Blood test revealed an hemoglobin
level of 9.2 g/dl, leucocytes 1540 x 10\textsuperscript{3}/\selectlanguage{greek}µ\selectlanguage{english}L, platelet
count 104000 x 10\textsuperscript{3}/\selectlanguage{greek}µ\selectlanguage{english}L, C-reactive protein 340 mg/dL,
Creatinine 170 \selectlanguage{greek}µ\selectlanguage{english}mol/L, Albumin 12g/dL, in addition to cytolysis and
cholestasis. Blood gas revealed a metabolic acidosis (pH=7.12) with high
arterial lactate levels of 8.9 mmol/L. The SOFA score was 9.

Emergency exploratory laparotomy was performed. On exploration, there
was a large amount of purulent fluid with global venous congestion.
However, inspection of the bladder, the uterus, the adnexa and the bowel
was without abnormality or any iatrogenic injury. Even the appendix was
macroscopically normal. Lavage of the peritoneal cavity was done and
pelvic drain was left in place. Mesenteric ischemia was suspected so
heparin 50 mg was administrated and post operatively a CT scan of the
abdomen was performed. It revealed intraperitoneal free fluid with
paralytic ileus but without any sign of arterial or venous thrombosis.
Fluid culture in addition to blood culture were positive for group A
streptococci. So finally, our diagnostic was primary peritonitis caused
by group A streptococci.

Post operatively and after the achievement of CT scan (figure 1), the
patient was transferred to the intensive care unit. Despite all efforts,
she remained in septic shock with multiorgan failure and disseminated
intravascular coagulation and died within 12h after admission.

\textbf{Discussion}

We presented a rare and unusual case of acute primary peritonitis due to
group A streptococci following vaginal delivery. This type of
peritonitis is caused by a mechanism which is not completely understood
until now, however there were some hypothesis which have been discussed
like for example hematogenous infection routes, retrograde inoculation
from genitourinary tract or increased translocation of intestinal
bacteria (4). In addition to that, some factors would predispose to the
development of primary peritonitis like liver cirrhosis,
immunosuppression or nephrotic syndrome, but it could also be seen in
young and healthy individuals (5).

In the last decades, we noticed an increase of gram-positive bacteria at
the expense of gram-negative one as a cause of primary peritonitis.
Although Lancefield group A streptococci, which were typically the cause
of pharyngitis, endocarditis or erysipelas, are rarely associated with
life threatening primary peritonitis (2,6).

According to the previous case reports published, there was a clear
predominance of healthy and young females (aged between 30 and 40
years), so ascending infection from genitourinary tract must be
considered as the first entry site to suspect (7--9). However, there are
other potential entry sites like for example the upper respiratory tract
or skin lesions, but in many cases, the source of GAS infection remained
unknown (10).

Concerning the clinical presentation, the vast majority of patient
described in the literature presented on admission severe abdominal pain
with high fever and secondary peritonitis was suspected (11). However,
the portal of entry was difficult to be deduced based on the symptoms or
physical examination, but in our case, it was probably the genital tract
because of the previous vaginal delivery. Although, it remains unclear
whether surgical exploration of the abdominal cavity is beneficial or
not, especially, for patient with negative CT scan where secondary
peritonitis could not be excluded (12,13). Rimawi et al (14) showed that
surgical treatment is beneficial in order to treat the streptococcal
toxic shock syndrome and it could explain the high rate of exploratory
surgery in young patients with acute onset of peritonitis. Thus, in some
cases and in order to prevent from surgery, GAS peritonitis could be
treated with antibiotics but a rapid antigen detection test should be
considered (15). However, Gisser et al (16) reported that despite an
early intravenous antibiotics there was no improvement in their patients
without surgery. Antibiotic therapy should be initiated rapidly (15) but
according to the literature there are few information in addition to
little consensus concerning the adequate antibiotic regimens which
should be used in case of GAS peritonitis (4). For uncomplicated GAS
infection, penicillin is recommended because it is well known that GAS
are sensitive to beta-lactam antibiotics (17), however in case of septic
patient, broad-spectrum antibiotics will be used and for example in our
case, an association of imipenem, amikacin and teicoplanin was used.

\textbf{Conclusion}

We presented a rare case of an acute primary peritonitis due to group A
streptococci following vaginal delivery in a young and healthy patient
complicated with septic shock and streptococcal toxic shock syndrome.
Despite of surgical treatment in addition to the broad-spectrum
antibiotics, it had a lethal issue within 12 hours. That is why
genitourinary tract should be considered as the main entry site in GAS
infection especially on post-partum period and an adequate therapy
should be initiated on time.

\textbf{Declaration}

\begin{itemize}
\tightlist
\item
  \emph{Conflicts of interest} : no conflict of interest
\item
  \emph{Authors contribution:}
\end{itemize}

\begin{itemize}
\tightlist
\item
  Dr Mohamed Aziz Daghmouri: Initial diagnostics and treatment of the
  patient and case report manuscript
\item
  Dr Fatma Zahra Affes: Initial diagnostics and treatment of the patient
  and case report manuscript
\item
  Dr Alia Jebri: Initial diagnostics and treatment of the patient
\item
  Dr Raja Boussassi: Initial diagnostics and treatment of the patient
\item
  Dr Sonia Ben Hamouda: Initial diagnostics and treatment of the patient
\item
  Dr Baddredine Bouguerra: Initial diagnostics and treatment of the
  patient
\item
  Dr Mohamed Houissa: Initial diagnostics and treatment of the patient
\item
  \emph{Ethics approval} : Not applicable
\item
  \emph{Consent for publication} : a consent was signed by a member of
  her family
\item
  \emph{Competing interests} : Not applicable
\item
  \emph{Funding} : we don't have any external funding
\item
  \emph{Acknowledgements} : we would like to express our appreciation to
  our department team for their valuable assistance
\item
  \emph{Availability of data and material~:} Not applicable
\end{itemize}

\textbf{Figure legend}

\emph{Figure 1: CT-scan of the abdomen showing intraperitoneal free
fluid with paralytic ileus but without}

\emph{any sign of arterial or venous thrombosis}

\textbf{References}

1. Stevens DL. Streptococcal toxic-shock syndrome: spectrum of disease,
pathogenesis, and new concepts in treatment. Emerging Infect Dis. sept
1995;1(3):69-78.

2. Lamagni TL, Darenberg J, Luca-Harari B, Siljander T, Efstratiou A,
Henriques-Normark B, et al. Epidemiology of severe Streptococcus
pyogenes disease in Europe. J Clin Microbiol. juill 2008;46(7):2359-67.

3. Stevens DL. Group A Streptococcal Sepsis. Curr Infect Dis Rep. oct
2003;5(5):379-86.

4. Solomkin JS. Evaluating evidence and grading recommendations: the
SIS/IDSA guidelines for the treatment of complicated intra-abdominal
infections. Surg Infect (Larchmt). juin 2010;11(3):269-74.

5. Martin J, Murchan S, O'Flanagan D, Fitzpatrick F. Invasive Group A
streptococcal disease in Ireland, 2004 to 2010. Euro Surveill. 13 oct
2011;16(41).

6. Luca-Harari B, Darenberg J, Neal S, Siljander T, Strakova L, Tanna A,
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7. Tilanus AMR, de Geus HRH, Rijnders BJA, Dwarkasing RS, van der Hoven
B, Bakker J. Severe group A streptococcal toxic shock syndrome
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8. Moskovitz M, Ehrenberg E, Grieco R, Chamovitz B, Burke M, Snyder D,
et al. Primary peritonitis due to group A streptococcus. J Clin
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by a peritonitis. Case report and review of the literature. Swiss Surg.
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11. Malota M, Felbinger TW, Ruppert R, N\selectlanguage{ngerman}üssler NC. Group A Streptococci:
A rare and often misdiagnosed cause of spontaneous bacterial peritonitis
in adults. International Journal of Surgery Case Reports. 1 janv
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in premenopausal adults in a sexual health setting. Sex Health. sept
2006;3(3):187\selectlanguage{english}-8.

13. Kanetake K, Hayashi M, Hino A, Futamura N, Mori Y, Takagi H, et al.
Primary peritonitis associated with streptococcal toxic shock-like
syndrome: report of a case. Surg Today. 2004;34(12):1053\selectlanguage{english}-6.

14. Rimawi BH, Soper DE, Eschenbach DA. Group A streptococcal infections
in obstetrics and gynecology. Clin Obstet Gynecol. dec
2012;55(4):864\selectlanguage{english}-74.

15. Little P, Hobbs FDR, Moore M, Mant D, Williamson I, McNulty C, et
al. Clinical score and rapid antigen detection test to guide antibiotic
use for sore throats: randomised controlled trial of PRISM (primary care
streptococcal management). BMJ. 10 oct 2013;347:f5806.

16. Gisser JM, Fields MC, Pick N, Moses AE, Srugo I. Invasive group a
streptococcus associated with an intrauterine device and oral sex. Sex
Transm Dis. aout 2002;29(8):483\selectlanguage{english}-5.

17. Walker MJ, Barnett TC, McArthur JD, Cole JN, Gillen CM, Henningham
A, et al. Disease manifestations and pathogenic mechanisms of Group A
Streptococcus. Clin Microbiol Rev. avr 2014;27(2):264\selectlanguage{english}-301.

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