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.