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.