REVIEW ARTICLE
Primary Peritonitis Due to Streptococcus pyogenes
Report of 2 Cases and Review of the 21st-Century Literature
Bahar Moftakhar, MD,* Yesha S. Patel, MD,* Jose E. Poblete, MD,†‡ and Joseph P. Myers, MD†‡
Introduction: Primary peritonitis (PP) is peritonitis occurring in patients
without underlying causes such as perforated viscus, preexisting ascites, or
nephrosis. We report 2 cases of primary Streptococcus pyogenes peritonitis
and review the literature on this subject since January 1, 2000.
Case Reports: Patient 1 was a 45-year-old woman who presented to hos-
pital with fever, diarrhea, and abdominal pain. Examination revealed fever,
hypotension, epigastric tenderness, and guarding. Computed tomography
(CT) scan was negative for signs of perforated viscus. Workup included
blood cultures, parenteral antibiotics, and surgical consult. She underwent
emergent operative intervention, which revealed generalized peritonitis,
cloudy peritoneal fluid, and no evidence of perforated viscus. Blood cul-
tures revealed S. pyogenes. She underwent an unremarkable recovery on
parenteral ceftriaxone followed by oral ampicillin. Patient 2 was a
47-year-old woman who presented to hospital with fever, chills, anorexia,
nausea, vomiting, and abdominal pain. Physical examination showed fever,
hypotension, tachycardia, and diffuse abdominal tenderness but no rebound
tenderness. Abdominal CT scan revealed fluid but no free air. Paracentesis
revealed purulent fluid, which on Gram-stained smear showed gram-positive
cocci in pairs and chains. Blood and peritoneal fluid cultures were positive
for S. pyogenes. Exploratory laparotomy by surgical consultant showed puru-
lent fluid and fibrinous exudate with multiple interloop abscesses and no
perforated viscus. Postoperatively, she received parenteral penicillin G,
transient hemodialysis, and ventilator support with eventual full recovery.
Review of Literature: We reviewed the medical literature from January
1, 2000, to December 31, 2016, and found 36 patients with diagnosis of S.
pyogenes PP. Despite most of these case reports stating that the occurrence
of S. pyogenes PP is “rare,” it seems that it is more common than previously
thought. All but 3 patients underwent surgical intervention. All 38 patients
presented with physical findings of an acute abdomen. There was no evi-
dence of free air on CT scanning or ultrasound of the 33 patients who
underwent one of these imaging techniques. Septic shock was common,
and all but 1 patient survived.
Conclusions: Streptococcus pyogenes PP is more common than previ-
ously reported, is associated with physical findings of acute abdomen, is usu-
ally accompanied by circulatory shock, and is almost always clinically
responsive to treatment with operative and antimicrobial agent interventions.
Key Words: group A streptococcus, primary peritonitis,
spontaneous peritonitis, Streptococcus pyogenes
(Infect Dis Clin Pract 2018;26: 66–70)
P rimary peritonitis (PP) is peritonitis occurring in patients with-
out underlying causes such as perforated viscus, preexisting
ascites, or nephrosis.1 It consists of peritonitis without a clear
From the *Internal Medicine Residency, Summa Health System/Northeast
Ohio Medical University Program; and †Department of Medicine, Infectious
Disease Division, Summa Health System, Akron; and ‡Infectious Disease Sec-
tion, Department of Internal Medicine, Northeast Ohio Medical University,
Rootstown, OH.
Correspondence to: Joseph P. Myers, MD, Department of Medicine, Summa
Akron City Hospital, 55 Arch St, Suite 1A, Akron, OH 44304.
E‐mail: myersj@summahealth.org.
The authors have no funding or conflicts of interest to disclose.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 1056-9103
66 www.infectdis.com Infectious Diseases in Clinical Practice • Volume 26, Number 2, March 2018
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
surgically amenable source. Primary peritonitis comprises less
than 1% of peritonitis cases encountered in a general surgical
practice.1 We report 2 patients with PP due to Streptococcus
pyogenes, group A streptococcus. We also review all patients re-
ported in the literature in the 21st century and provide an updated
perspective of this clinical entity.
MATERIALS AND METHODS
PubMed, Google, and Google Scholar searches were per-
formed using all combinations of the following key words/
phrases: Streptococcus pyogenes, group A streptococcus, group
A strep, peritonitis, primary peritonitis, and spontaneous peritonitis.
Articles obtained from these searches and their bibliographies
were reviewed to identify other patients with primary S. pyogenes
peritonitis in adult patients (aged ≥16 years). These patients are
listed in Table 1.2–27
CASE STUDIES
Patient 1
A 47-year-old healthy woman presented to the emergency
department with a 7-day history of sharp chest pain, dyspnea, pro-
ductive cough, abdominal pain, nausea, vomiting, and anorexia.
Review of systems was also positive for diaphoresis, fever, chills,
cough productive of brown sputum, and generalized weakness.
Surgical history was positive for cesarean delivery and tubal liga-
tion. There was no history of tobacco use or drug or alcohol abuse,
and there was no history of immunosuppressive illnesses or im-
munosuppressive medications having been received by the pa-
tient. Physical examination revealed a very acutely ill-appearing
woman with vital signs as follows: temperature, 102.0°F; blood
pressure, 89/0 mm Hg; pulse, 144 beats/min; respiratory rate,
38 breaths/min. Oxygen saturation was 95% on room air. Patient
was diaphoretic and in moderate to severe distress from abdomi-
nal pain. The abdomen was distended and revealed generalized
tenderness to palpation, as well as rebound tenderness and associ-
ated guarding. The remainder of the physical examination was
normal. Laboratory data included white blood cell (WBC) count
of 28,700/μL (reference range, 4400–11,300/μL); total bilirubin,
2.3 mg/dL (reference range, 0.0–1.3 mg/dL); alanine aminotrans-
ferase, 101 U/L (reference range, 14–54 U/L); aspartate amino-
transferase, 85 U/L (reference range, 15–41 U/L); and lactate,
9.4 mmol/L (reference range, 0.6–2.0 mmol/L). Analysis of the
peritoneal fluid obtained by paracentesis revealed a WBC count
of 545,000/μL with a differential count of 97% neutrophils, 2%
lymphocytes, and 1% monocytes. Blood and peritoneal fluid cul-
tures were positive for S. pyogenes. Anaerobic cultures of perito-
neal fluid remained negative. Computed tomography (CT) scan
of the abdomen/pelvis revealed significant amounts of fluid in
the pelvis. Paracentesis revealed purulent fluid with gram-
positive cocci in chains on Gram-stained smear. Surgical consult
was obtained, and patient was taken directly to surgery suite for
acute abdomen. Laparotomy revealed purulent material among
bowel loops but no perforated viscus upon running of the entire
 TABLE 1. Primary Peritonitis Due to S. pyogenes (Group A Streptococcus) in the 21st Century

Acute Tmax, Shock Primary Positive

Patient Year Author Sex Age, y Abdomen °C Present Complaint Imaging Surgery Cultures Antibiotic Therapy Comment Outcome
1 2000 Moskovitz F 39 Yes 39.0 Yes Abdominal pain, None Laparotomy Blood, vaginal swab Levofloxacin (IV) + metronidazole (IV) Vaginitis 3 days Lived
et al2 diarrhea then ceftriaxone (IV) + prior (positive
ampicillin/sulbactam (IV) culture)
2 2001 Borgia et al3 F 36 Yes 39.0 No Abdominal pain, None Laparoscopy Blood, vaginal swab, Clindamycin (IV) + gentamicin (IV) Lived
diarrhea, nausea peritoneal fluid then penicillin G (IV) +
clindamycin (IV) then amoxicillin (PO)
3 2001 Sanchez and M 34 Yes 40.1 No Abdominal pain CT Laparoscopy Peritoneal fluid Piperacillin/tazobactam (IV) then Lived
Lancaster4 penicillin G (IV) + clindamycin (IV)
then cephalexin (PO) + clindamycin (PO)
4 2001 Vuilleumier F 33 Yes 39.0 Yes Fever, abdominal None Laparotomy Blood, peritoneal Imipenem/cilastatin (IV) then 2 months Lived
and Halkic5 pain, diarrhea fluid meropenem (IV) + clindamycin (IV) post-partum
5 2002 Fox et al6 F 39 Yes 37.2 Yes Abdominal pain US, CT Laparotomy Peritoneal fluid, Clindamycin (IV) + Menses 2 days prior, Lived
abdominal tissue piperacillin/tazobactam (IV) Uses tampons
7
6 2002 Gavala et al M 40 Yes 39.0 Yes Abdominal pain CT Laparotomy Peritoneal fluid (with Piperacillin/tazobactam (IV) + Pharyngitis 7 days Lived
Escherichia coli) metronidazole (IV) + netilmicin (IV) then prior

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7 2004 Okumura F 29 Yes 38.0 No Abdominal pain CT Laparoscopy then Peritoneal fluid Imipenem/cilastatin (IV) + Cesarean section Lived
et al8 Laparotomy metronidazole (IV) then imipenem/ 5 weeks
cilastatin (IV) + clindamycin (IV) previously
8 2004 Kanetake M 40 Yes 38.0 Yes Femoral area pain XR, CT, Laparotomy Peritoneal fluid “Antibiotics” (IV) Strep Lived
et al9 then abdominal US throat 3 days prior
pain
9 2005 Brivet et al10 F 54 Yes 39.5 No Abdominal pain, CT Laparoscopy Blood Lomefloxacin (PO) then amoxicillin/ Lived
fever clavulanate (IV) + gentamicin (IV)
10 2005 Brivet et al10 F 82 Yes 39.0 Yes Abdominal pain, CT None Blood Amoxicillin/clavulanate (IV) Lived
diarrhea, vomiting
11 2006 Saha et al11 F 23 Yes 39.0 No Abdominal pain, CT, US Laparotomy Blood Ceftriaxone (IV) + metronidazole (IV) + Menses 2 days Lived
Infectious Diseases in Clinical Practice • Volume 26, Number 2, March 2018

diarrhea, vomiting doxycycline (PO) then penicillin G (IV) + prior

clindamycin (IV) + ciprofloxacin (IV)
12 2006 Jarvis et al12 F 38 Yes 39.6 Yes Abdominal pain, CT Laparoscopy then Blood Amoxicillin (IV) + Gentamicin (IV) + Cesarean section Lived
vomiting, diarrhea Laparotomy metronidazole (IV) then cefuroxime (IV) + 13 weeks prior
gentamicin (IV) + metronidazole (IV) +
penicillin G (IV)
13 2006 Jarvis et al12 F 30 Yes ND No Vaginal discharge, CT Laparoscopy then Blood, peritoneal Amoxicillin (IV) + metronidazole (IV) then Cesarean section Lived
abdominal pain, Laparotomy fluid, vaginal amoxicillin (IV) + metronidazole (IV) + 12 weeks prior
rigors, nausea swabs cefuroxime (IV) + penicillin G (IV)
14 2008 Van Lelyveld- F 28 Yes 39.4 Yes Abdominal pain None Laparotomy Blood, peritoneal Piperacillin/tazobactam (IV) then Lived
Haas et al13 fluid, vaginal penicillin G (IV)
swabs

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15 2008 Doloy et al14 F 35 Yes 40.1 No Fever, chills, US Diagnostic Peritoneal fluid ciprofloxacin (PO) then Ceftriaxone (IV), Lived
abdominal pain paracentesis ofloxacin (IV),metronidazole (IV)
then amoxicillin/clavulanate (IV) +
gentamicin (IV)
16 2009 Kinsella et al15 M 38 Yes 39.0 Yes Nausea, anorexia, CT Laparotomy Blood, peritoneal Amoxicillin (IV) + metronidazole (IV) + Vesicles on legs at Lived
fever, abdominal fluid, insect bite gentamicin (IV), ciprofloxacin (IV) insect bite sites
pain skin lesion added postoperatively (+ culture)
17 2009 Thomas et al16 F 37 Yes 38.6 Yes Abdominal pain, CT Laparotomy Cervical swab Ceftriaxone (IV) + ornidazole (IV) + 2 days postpartum Lived
vomiting, fever gentamicin (IV) then clindamycin (IV)
added
18 2009 Thomas et al16 M 36 Yes 39.0 Yes Diarrhea and shock CT Laparotomy Blood, peritoneal Amoxicillin (IV) + clindamycin (IV) + Amputation of Lived
fluid gentamicin (IV) hands required

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Continued next page

67
Primary Peritonitis Due to S. pyogenes
 TABLE 1. (Continued)

68
Acute Tmax, Shock Primary Positive
Patient Year Author Sex Age, y Abdomen °C Present Complaint Imaging Surgery Cultures Antibiotic Therapy Comment Outcome
19 2010 Tilanus et al17 F 35 Yes 38.5 Yes Diarrhea then CT Laparotomy Blood Amoxicillin/clavulanate (IV) + Lived
Moftakhar et al

abdominal pain clindamycin (IV) + gentamicin (IV)

then penicillin G (IV) + clindamycin (IV)
20 2010 Monneuse M 35* Yes ND No ND CT Laparotomy Blood ND Lived
et al18
21 2010 Monneuse F 35* Yes ND Yes ND CT Laparotomy Blood ND Lived

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et al18
22 2010 Monneuse F 35* Yes ND Yes ND CT Laparotomy Blood, peritoneal ND Lived
et al18 fluid
23 2010 Monneuse F 35* Yes ND Yes ND CT Laparotomy Blood, peritoneal ND Lived
et al18 fluid, Wound
24 2010 Monneuse F 35* Yes ND Yes ND CT Laparotomy Blood, peritoneal ND Lived
et al18 fluid
25 2010 Monneuse F 35* Yes ND Yes ND CT Laparotomy Blood, peritoneal ND Lived
et al18 fluid
26 2010 Haap et al19 F 27 Yes 39.4 Yes Abdominal pain, US, CT Laparotomy Blood Piperacillin/tazobactam (IV) + Lived
nausea, diarrhea metronidazole (IV) + ciprofloxacin (IV)
20
27 2011 Legras et al F 23 Yes 39.0 Yes Abdominal pain, CT Laparoscopy Fibrinopurulent Ceftriaxone (IV) + metronidazole (IV) + Lived
vomiting membranes at levofloxacin (IV) then amoxicillin (PO)
surgery
28 2012 Park et al21 F 29 Yes 38.0 Yes Abdominal pain CT Laparoscopy Blood, peritoneal Ampicillin/sulbactam (IV) then Menses 3 wks Lived
fluid, cervical penicillin G (IV) + metronidazole (IV) prior
swab
29 2012 Preece et al22 F 17 Yes 39.5 Yes Abdominal pain, CT Laparoscopy Peritoneal fluid Penicillin G (IV) then penicillin V (PO) + Pharyngitis Lived
vomiting, diarrhea metronidazole (PO) + doxycycline (PO) 2 wks prior
23
30 2014 Munros et al F 21 Yes 36.7 Yes Abdominal pain CT Laparoscopy then Peritoneal fluid Clindamycin (IV) + gentamicin (IV) Lived
Laparotomy then piperacillin/tazobactam (IV) +
doxycycline (IV)
31 2014 Nogami et al24 F 40 Yes 35.8 Yes Anorexia, myalgias, CT Laparotomy Blood, peritoneal Meropenem (IV) + vancomycin (IV) Lived
abdominal pain fluid then ampicillin/sulbactam (IV)
25
32 2015 Kaneko et al F 28 Yes 40.0 Yes Abdominal pain, CT No Blood Cefmetazole (IV) + minocycline (IV) then Lived
diarrhea penicillin G (IV) + clindamycin (IV)
26
33 2015 Malota et al F 23 Yes 39.1 Yes Abdominal pain None Laparoscopy then Blood, peritoneal Piperacillin/tazobactam (IV) then Tonsillitis few Died
Laparotomy fluid days prior
(second-look)
34 2015 Malota et al26 F 34 Yes ND Yes Abdominal pain CT Laparotomy Blood, peritoneal Cefazolin (IV) + metronidazole (IV) then Hysteroscopic Lived
fluid Imipenem (IV) + vancomycin (IV) removal of
intrauterine

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pessary
8 days prior
35 2015 Malota et al26 F 36 Yes 38.9 Yes Lower abdominal CT Laparotomy Blood, peritoneal Piperacillin/tazobactam Husband had GAS Lived
pain fluid pharyngitis
5 days prior
36 2016 Abellán F 60 Yes 38.7 Yes Abdominal pain, CT Laparoscopy Peritoneal fluid “Wide-spectrum antibiotics” Lived
Morcillo somnolence
et al27
37 2017 This series— F 45 Yes 38.8 Yes Nausea, vomiting, CT Laparotomy Blood Piperacillin/tazobactam (IV) then Lived
patient 1 diarrhea, ceftriaxone (IV) then
abdominal pain ampicillin/sulbactam (IV)
38 2017 This series— F 47 Yes 38.8 Yes Abdominal pain, CT Laparotomy Blood, peritoneal Ceftriaxone (IV) + ciprofloxacin (IV) + Lived
patient 2 nausea, vomiting, fluid vancomycin (IV) then penicillin G (IV)
anorexia

F indicates female; IV, intravenous; M, male; ND, no data available; PO, per os (oral); Tmax, maximum recorded temperature; XR, x-Ray finding.

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Infectious Diseases in Clinical Practice • Volume 26, Number 2, March 2018
Infectious Diseases in Clinical Practice • Volume 26, Number 2, March 2018
FIGURE 1. Streptococcus pyogenes PP by year.
length of bowel. The patient was treated initially with parenteral
vancomycin and piperacillin/tazobactam. When the cultures were
finalized, she was treated with parenteral penicillin G followed by
oral ampicillin to complete 2 weeks of treatment. She remained
well 1 year after surgical intervention.
Patient 2
A 45-year-old woman presented to the emergency depart-
ment with a 2-day history of nausea, vomiting, diarrhea, and de-
creased oral intake. She was initially diagnosed as having viral
gastroenteritis and released to home with symptomatic therapy.
She did not improve and returned to the emergency department
2 days later when the blood culture from her first visit was positive
for S. pyogenes. When she returned, she had prior symptoms plus
right-upper-quadrant abdominal pain and cough. Review of sys-
tems upon return was positive for symptoms already noted plus
fever and chills. Her surgical history was positive for remote ce-
sarean delivery. There has no history of tobacco use or alcohol
or substance abuse, and there was no history of immunosuppres-
sive illness or immunosuppressive drug administration. Physical
examination revealed vital signs as follows: temperature, 98.5°F;
blood pressure, 100/59 mm Hg; pulse, 133 beats/min; respiratory
rate, 20 breaths/min. Oxygen saturation was 96.7% on room air.
The patient appeared visibly toxic and dyspneic. Positive physical
findings were confined to the abdomen, which showed general-
ized tenderness to palpation, which was significantly worse in
the right upper quadrant. Guarding was also evident. Laboratory
data revealed a WBC count of 13,700/μL (reference range,
4400–11,300/μL); serum lactate, 2.7 mmol/L (reference range,
0.6–2.0 mmol/L); blood urea nitrogen, 54 mg/dL (reference
range, 4–22 mg/dL); and serum creatinine, 6.64 mg/dL (reference
range, 0.60–1.40 mg/dL); 2 blood cultures were eventually posi-
tive for S. pyogenes. The patient was given 1 dose of parenteral
vancomycin and parenteral piperacillin/tazobactam, and stat
FIGURE 2. Underlying conditions—S. pyogenes PP.
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Primary Peritonitis Due to S. pyogenes
surgical consultation was obtained in the emergency department.
Patient was diagnosed as having an acute abdomen and was
taken immediately to the operative suite for emergency explor-
atory laparotomy where they found widespread purulent mate-
rial in the abdominal cavity but no evidence of perforated
viscus. Gram-stained smear of the purulent material revealed
many polymorphonuclear leukocytes and many gram-positive
cocci in pairs and chains. Aerobic and anaerobic cultures of peri-
toneal material remained negative, but the patient had received
emergent doses of vancomycin and piperacillin/tazobactam
in the emergency department after blood cultures were ob-
tained. Once blood cultures were finalized, the patient's antimi-
crobial regimen was changed to parenteral ceftriaxone and
eventually to oral amoxicillin to complete 2 weeks of treatment.
The patient's serum creatinine decreased to 1.73 mg/dL on the
second postoperative day and returned to normal (1.37 mg/dL)
by the 11th postoperative day. She remains well 6 months after
laparotomy.
DISCUSSION
In our review of the literature, we found 36 adult patients re-
ported since January 1, 2000, with a diagnosis of PP due to S.
pyogenes (group A streptococcus).2–27 These patients are listed
in Table 1. Along with our 2 patients, there are 38 patients. Al-
though most of these reports stated that PP due to group A strep-
tococcus is rare, this entity may be more common than originally
thought (Fig. 1). Thirty-two (84.2%) of 38 patients were women,
and patient ages ranged from 17 to 60 years, with a mean age of
36.0 years. All patients presented with physical findings compat-
ible with an acute surgical abdomen. Most patients had no signif-
icant underlying conditions (Fig. 2). There was no evidence of
free air on radiographic studies in any of the patients. Twenty-
eight patients (73.7%) underwent CT scanning alone, 4 (10.5%)
underwent CT scanning + ultrasound, and 1 (2.6%) of the patients
underwent ultrasound alone. Five patients (13.2%) had no imag-
ing studies performed. Sites for positive cultures for S. pyogenes
are shown in Figure 3. Thirty-one of 38 patients presented with or
quickly developed septic shock. Thirty-five (92.1%) of 38 patients
underwent surgical intervention. Most patients underwent surgical
intervention because it was impossible for the surgeon to differen-
tiate primary from secondary peritonitis. Twenty-three patients
(60.5%) underwent laparotomy alone, 7 (18.4%) underwent lapa-
roscopy alone, and 5 (13.2%) underwent laparoscopy converted to
laparotomy. One patient (2.6%) had paracentesis alone, and
2 patients (5.3%) had no intervention. Thirty-seven (97.4%) of
38 patients survived, and 1 patient (2.6%) died.
CONCLUSIONS
Primary peritonitis caused by S. pyogenes is more common
than previously thought.2–27 All patients reported in this century
www.infectdis.com 69
Moftakhar et al Infectious Diseases in Clinical Practice • Volume 26, Number 2, March 2018
FIGURE 3. Positive culture sites—S. pyogenes PP.
presented with an acute abdomen, and 92.1% of patients under-
went almost immediate surgical intervention, often because a per-
forated viscus could not be excluded by physical examination and/
or radiographic techniques. None of the patients who had radio-
graphic studies showed the presence of free air on either ultra-
sound or CT examination. Clinicians should be aware of this
entity once considered “rare.” It is certainly not common, but
emergency medicine physicians, critical care specialists, surgeons,
hospitalists, and infectious disease specialists should have a high
index of suspicion for this pathogen and clinical entity causing
peritonitis especially when peritonitis presents with acute abdom-
inal findings with septic shock in the absence of free air on
radiographic examination.
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