Introduction
In an unusual presentation of pediatric illness, an 11-year-old girl with no history of underlying health conditions developed primary peritonitis caused by group A Streptococcus pyogenes (S. pyogenes). This rare case has caught the attention of pediatricians and infectious disease experts due to its atypical onset and presents a challenge in pediatric healthcare.
The BMJ Case Reports journal recently published a case (DOI: 10.1136/bcr-2019-229186) detailing the situation of a previously healthy 11-year-old girl who arrived at the hospital with symptoms resembling an acute abdomen. Upon further examination and investigation, it was revealed that the patient was suffering from primary peritonitis associated with a group A streptococcal infection originating in the pharynx, a condition rarely seen in pediatric patients.
Primary peritonitis is an infection of the peritoneal cavity that occurs without an apparent intraperitoneal source and is a rare entity in children. This condition is often mistaken for appendicitis due to similar clinical presentations, which can include severe abdominal pain, fever, and gastrointestinal symptoms. However, while appendicitis requires surgical intervention, the treatment for primary peritonitis is primarily antimicrobial therapy.
Case Presentation
The young girl was admitted with severe abdominal pain, fever, vomiting, and other systemic symptoms. Clinical evaluation and imaging studies initially suggested appendicitis, which led to a surgical consultation. However, following surgery, the typical signs of appendicitis were absent, and laboratory findings revealed S. pyogenes in the peritoneal fluid cultures. Ultimately, the diagnosis was corrected to S. pyogenes-associated primary peritonitis.
Treatment and Outcome
The patient was treated with an amoxicillin-potassium clavulanate combination and other supportive measures. The case report notes that the treatment resulted in a positive outcome, highlighting the importance of early and accurate diagnosis for successful management of this unusual condition.
Discussion
With such an extraordinary presentation, the case highlights the critical need for a thorough differential diagnosis in pediatric cases of acute abdomen. The difficulty in diagnosing primary peritonitis lies in its nonspecific presentation and the rarity of the condition, which makes it less likely to be considered initially by clinicians. Furthermore, there is a lack of awareness about S. pyogenes as a rare cause of primary peritonitis in otherwise healthy children. S. pyogenes is a bacterium best known for causing streptococcal pharyngitis, or “strep throat,” and in some cases, post-streptococcal complications such as rheumatic fever.
The literature review shows that there have been very few reported cases of this nature, accentuating the novelty of this case (Dann et al., 2005; Freij et al., 1984; Chomton et al., 2017). S. pyogenes has been found to be a culprit in primary peritonitis predominantly in adult women and less commonly in children, with a unique propensity to affect female adolescents (Sewrey et al., 2009; Blevrakis et al., 2016).
Research Context
A deep dive into past literature from Rangel, S. et al., Ladd, W.E. et al., and Cunningham, M.W. (2000) has documented the pathogenicity of group A Streptococcus and its associated complications, but primary peritonitis remains an outlier regarding its route of infection and presentation in pediatric cases. Previous cases serve to inform the current understanding of S. pyogenes infections and reinforce the necessity for healthcare providers to consider this rare diagnosis, particularly when exploratory surgery does not reveal a source for the infection (Westwood & Roberts, 2013; Auskalnis et al., 2004).
Public Health Implications
This case carries substantial public health implications as it underscores potential diagnostic pitfalls, emphasizes the need for rapid and appropriate treatment, and may influence further research into the prevention of invasive streptococcal infections. Education campaigns that improve clinician awareness of such atypical presentations of common pathogens can significantly impact patient outcomes and prevent potential complications.
Keywords
1. Primary Peritonitis Pediatrics
2. Group A Streptococcal Infection
3. Acute Abdomen in Children
4. Pediatric Infectious Diseases
5. Streptococcus Pyogenes Complications
References
1. Dann, P.H., Amodio, J.B., Rivera, R., et al. (2005). ‘Primary bacterial peritonitis in otherwise healthy children: imaging findings.’ Pediatric Radiology, 35, 198–201. DOI: 10.1007/s00247-004-1304-7
2. Freij, B.J., Votteler, T.P., McCracken, G.H. (1984). ‘Primary peritonitis in previously healthy children.’ American Journal of Diseases of Children, 138, 1058. DOI: 10.1001/archpedi.1984.02140490058014
3. Chomton, M., Emeriaud, G., Bidet, P., et al. (2017). ‘Group A streptococcal primary peritonitis in a healthy girl.’ Journal of Paediatrics and Child Health, 53, 615–6. DOI: 10.1111/jpc.13584
4. Sewrey, H., Bryant, P.A. (2009). ‘Group A streptococcus causing primary peritonitis in a healthy infant.’ Pediatric Infectious Disease Journal, 28, 1146. DOI: 10.1097/INF.0b013e3181bdbd9f
5. Rangel, S., Rice-Townsend, S., Karki, M., et al. (2018). ‘Peritonitis.’ In: Long, S.S., Prober, C.G., Fischer, M. (eds.), Principles and Practice of Pediatric Infectious Diseases. Philadelphia, PA: Elsevier, Inc., pp. 423–8.
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