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°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 µg/kg/min to a maximum of 2 µg/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 103/µL, platelet count 104000 x 103/µL, C-reactive protein 340 mg/dL, Creatinine 170 µmol/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.