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.