Primary Group A Streptococcal Peritonitis Complicated by Acute Renal Failure

We report a case of primary group A Streptococcal peritonitis complicated by acute renal failure in a previously healthy 35-year-old woman. The patient complained of a 30-hour history of fever and lower abdominal pain. She was anuric, but not in shock on hospital admission. Her abdomen was slightly tender and rebound tenderness and muscle guarding were observed. Laboratory examination revealed leukocytosis (WBC 14, 300/mm3) with a shift to the left, and azotemia (BUN 106mg/dl, Cre 7.5mg/dl). A clinical diagnosis primary peritonitis was suggested, and laparotomy was performed with initiation of fluid resuscitation. At operation, purulent ascites was observed, but no gastrointestinal tract perforation could be identified. Abdominal lavage and drainage were conducted. Postoperatively, hemofiltration was carried out for acute renal failure, and urination returned on the 11th postoperative day. On microbiological investigation, group A Streptoccus (S. pyogenes) (serotype T1/M1, Streptococcal pyogenic exotoxin: SPE/A+B) was detected in the intraperitoneal pus. Serum analysis revealed interleukin-6 level of 3, 910pg/ml, thrombomodulin 8.1FU/ml, and tissue plasminogen activator·plasminogen activator inhibitor-1 complex (t-PAI·C) 124ng/ml. Discussion of the relevance of these findings to toxic shock-like syndrome (TSLS) is included.