Malota Mark, Felbinger Thomas W, Ruppert Reinhard, Nüssler Natascha C
Department of General and Visceral Surgery, Endocrine Surgery and Coloproctology, Klinikum Neuperlach, Städtisches Klinikum München GmbH, Munich, Germany.
Department of Anesthesiology, Critical Care and Pain Medicine, Klinikum Neuperlach, Städtisches Klinikum München GmbH, Munich, Germany.
Int J Surg Case Rep. 2015;6C:251-5. doi: 10.1016/j.ijscr.2014.10.060. Epub 2014 Dec 11.
Acute primary peritonitis due to group A Streptococci (GAS) is a rare but life-threatening infection. Unlike other forms of primary peritonitis it affects predominantly young previously healthy individuals and thus is often confused with the more frequent secondary peritonitis. A case series of three patients is presented as well as a review of the literature focusing on pitfalls in the diagnose and therapy of GAS peritonitis.
A retrospective analysis of three patients with primary GAS peritonitis was performed. Furthermore a systematic review of all cases of primary GAS peritonitis published from 1990 to 2013 was performed comparing demographics and clinical presentation, as well as radiological imaging, treatment and outcome.
All three female patients presented initially with high fever, nausea and severe abdominal pain. Radiological imaging revealed intraperitoneal fluid collections of various degrees, but no underlying cause of peritonitis. Broad antibiotic treatment was started and surgical exploration was performed for acute abdomen in all three cases. Intraoperatively fibrinous peritonitis was observed, but the correct diagnosis was not made until microbiological analysis confirmed GAS peritonitis. One patient died within 24h after admission. The other two patients recovered after multiple surgeries and several weeks on the intensive care unit due to multiple organ dysfunction syndrome. The fulminant clinical course of the three patients resembled those of many of the published cases: flu-like symptoms, high fever, severe acute abdominal pain and fibrinous peritonitis without obvious infectious focus were the most common symptoms reported in the literature.
GAS primary peritonitis should be considered in particular in young, previously healthy women who present with peritonitis but lack radiological findings of an infectious focus. The treatment of choice is immediate antibiotic therapy. Surgical intervention is difficult to avoid, since the diagnosis of GAS peritonitis is usually not confirmed until other causes of secondary peritonitis have been excluded.
A 组链球菌（GAS）引起的急性原发性腹膜炎是一种罕见但危及生命的感染。与其他形式的原发性腹膜炎不同，它主要影响先前健康的年轻个体，因此常与更常见的继发性腹膜炎相混淆。本文介绍了三例病例系列，并对文献进行综述，重点关注 GAS 腹膜炎诊断和治疗中的陷阱。
对三例原发性 GAS 腹膜炎患者进行回顾性分析。此外，对 1990 年至 2013 年发表的所有原发性 GAS 腹膜炎病例进行系统综述，比较人口统计学和临床表现，以及放射学影像、治疗和结局。
所有三名女性患者最初均表现为高热、恶心和严重腹痛。放射学影像显示不同程度的腹腔积液，但未发现腹膜炎的潜在病因。开始使用广谱抗生素治疗，并对所有三例患者进行了急腹症手术探查。术中观察到纤维蛋白性腹膜炎，但直到微生物分析确诊为 GAS 腹膜炎才做出正确诊断。一名患者在入院后 24 小时内死亡。另外两名患者因多器官功能障碍综合征在多次手术后及重症监护病房住院数周后康复。这三名患者的暴发性临床病程与许多已发表病例相似：流感样症状、高热、严重急性腹痛和无明显感染灶的纤维蛋白性腹膜炎是文献中报道最常见的症状。
对于出现腹膜炎但缺乏感染灶放射学表现的年轻、先前健康的女性，应特别考虑 GAS 原发性腹膜炎。首选治疗方法是立即进行抗生素治疗。由于通常在排除继发性腹膜炎的其他病因后才确诊 GAS 腹膜炎，因此难以避免手术干预。
