Streptococcus pneumoniae primary peritonitis mimicking acute appendicitis in an immunocompetent patient: a case report and review of the literature

Abstract

Introduction Primary peritonitis without an identifiable intra-abdominal source is extremely rare in healthy individuals; it is commonly seen in cases of nephrotic syndrome, cirrhosis and end-stage liver disease, ascites, immunosuppression, and inflamed peritoneum due to pre-existing autoimmune and oncological conditions. Case presentation We present the case of a 68-year-old Caucasian woman operated on due to acute abdomen with a provisional diagnosis of acute appendicitis. During the operation a small amount of free intra-abdominal fluid was found. Her uterus, ovaries, and fallopian tubes were macroscopically normal. Therefore, with the suspicion of appendicitis, appendectomy was performed. Her blood cultures were negative while peritoneal fluid was positive for capsulated form of Streptococcus pneumoniae . A 30-day follow-up was performed and she was asymptomatic without any sign of infection. Discussion Streptococcus pneumoniae commonly causes upper respiratory tract infection and cutaneous infections. It very rarely causes gastrointestinal infection and it is very rarely responsible for primary peritonitis and septic shock syndrome. Conclusion Pneumococcal peritonitis has a rare occurrence and represents a clinical challenge because of its subtle and non-specific clinical findings. The interest in our case lays in the relatively rare diagnosis of primary peritonitis mimicking acute appendicitis.

Primary pneumococcal peritonitis can be the first presentation of a familial complement factor I deficiency1

“…It is arguable, therefore, if all the 40 cases truly represent pneumococcal peritonitis without a predisposing factor. However, as in our case, pneumococcal peritonitis can sometimes mimic appendicitis [17], so historical underdiagnosis in men and women is possible.…”

“…It is currently thought to represent three distinct clinical groups: (a) pneumococcal peritonitis associated with liver disease, infectious hepatitis, cirrhosis, ascites, nephrotic syndrome, chronic renal failure and continuous ambulatory peritoneal dialysis, autoimmune disease or known immunocompromise including HIV [11], (b) pneumococcal peritonitis associated with gastrointestinal disease including appendicitis or after intra‐abdominal surgery [12] and (c) pneumococcal peritonitis sometimes, but not always, presenting with an apparent genitourinary focus in otherwise healthy young women. We identified 40 published descriptions of the latter [13–17]. The fact that the disease is more common among women is thought to represent an infection source from the female genital tract or an ascending infection from the vagina: the latter is also supported by the fact that 13 of 40 women had an intrauterine contraceptive device (IUCD) in place, five of 40 were pregnant or postpartum and at least seven of 40 had a clinical diagnosis of pelvic inflammatory disease.…”

Pattern of acute abdomen in a Tertiary hospital in Nigeria

“…Primary peritonitis comprises of 2% of all abdominal emergencies 17 in children, but rarer in adults. It is very rare in healthy individuals (2%) 18 . Other conditions include gangrenous and perforated gall bladder, vaso-occlusive crisis in HBSS patients, bladder injury following blunt abdominal injury secondary to trauma.…”

Atypical case presentations of Streptococcus pneumoniae from level 1 trauma centre in India -A case series

“…The clinical picture usually mimics appendicitis or secondary peritonitis with or without sepsis. [ 5 ] The predisposing factors for pneumococcal infections include splenectomy, alcohol consumption, connective tissue disorders, steroid use, diabetes mellitus, and intravenous drug use. [ 6 ] The real clinical challenge for the clinicians arises when it occurs in immonocompetent healthy young adults with no risk factors.…”