Primary pneumococcal peritonitis with a fulminant course

Primary peritonitis is an inflammation of the peritoneal cavity in the absence of a localized intra-abdominal source. It is included in the differential diagnosis of acute abdomen and can be potentially life-threatening. Pneumococci were a frequent pathogen causing primary peritonitis especially in the preantibiotic era. Nowadays, they act as an uncommon primary pathogen. Pneumococcal peritonitis in adults is more frequently seen in cases of liver cirrhosis with ascites and other pre-existing conditions. Primary pneumococcal peritonitis is uncommon in healthy individuals and therefore its diagnosis is difficult. Secondary peritonitis has to be excluded.

A 36-year-old woman was admitted to our surgery department with symptoms of severe sepsis. She reported a sudden onset of diffuse abdominal pain and was eight weeks after delivery per vias naturales. A computed tomography scan of the abdomen with intravenous contrast has not demonstrated any pathology explaining the condition of our patient. Empiric anti-microbial therapy with broad-spectrum antibiotics was commenced and a laparotomy was performed, which also did not reveal any source of infection. Purulent odorless fluid was found in the peritoneal cavity. Peritoneal lavage with an antiseptic was performed. Cultures from peritoneal fluid demonstrated a monobacterial growth of Streptococcus pneumoniae. The condition of our patient improved after continued adequate antibiotic therapy and lavage.

Primary pneumococcal peritonitis is difficult to diagnose in healthy individuals, since it is mimicking secondary peritonitis that has to be excluded. A clinical diagnose without surgical intervention is impossible in most cases. Surgical treatment has an important role in both the diagnosis and management of primary pneumococcal peritonitis, same as adequate antibiotic therapy. Primary peritonitis should be a part of the differential diagnosis of patients presenting with acute abdominal pain.