we encountered a case where an infection with group a streptococcus ( gas ; ie , streptococcus pyogenes ) initially caused primary peritonitis and then subsequently caused streptococcal toxic shock syndrome .
the patient s life was likely saved by an emergency laparotomy followed by extensive peritoneal lavage and drainage .
a 40-year - old woman was admitted to the emergency department for lower abdominal pain and numbness in the extremities .
an emergency laparotomy was performed , and ascites that resembled pus and general peritonitis were noted .
the patient was diagnosed with streptococcal toxic shock syndrome due to an ascending gas infection originating from vagina .
streptococcal toxic shock syndrome ( stss ) is a condition that suddenly and rapidly progresses as a result of an infection with group a streptococcus ( gas ; ie , streptococcus pyogenes ) .
this condition can lead to septic shock , acute respiratory distress syndrome ( ards ) , disseminated intravascular coagulation ( dic ) , or multiple organ failure , which accounts for its high fatality rate .
as reported , we encountered a case where gas initially caused primary peritonitis and subsequently caused stss . in the case in question ,
the patient s life was likely saved by performing an emergency laparotomy followed by extensive peritoneal lavage and drainage .
a 40-year - old woman was admitted to the emergency department of aomori prefectural central hospital for lower abdominal pain and numbness in the extremities that developed 14 hours prior .
she was on day 6 of her menstrual cycle , had a temperature of 37.9 c , a blood pressure of 92/46 mmhg , a heart rate of 97 beats / min , and an oxygen saturation of peripheral artery ( spo2 ) of 96% .
blood test results were as follows : white blood cell ( wbc ) count of 8100/l , hemoglobin ( hb ) of 6.2 g / dl , platelet ( plt ) count of 46.2  10/l , c - reactive protein ( crp ) of 9.61 mg / dl , blood urea nitrogen ( bun ) of 20.1 mg / dl , and creatinine of 1.52 mg / dl .
uterine fibroids , ascites , and thickening of the peritoneum were suggested , and intraabdominal hemorrhage was also a possibility , but computed tomography ( ct ) scan failed to reveal any obvious sources of bleeding .
a pelvic infection was suspected , so the patient was admitted and azithromycin ( azm ) 500 mg / d was started .
however , 29 hours after initial presentation , abdominal pain intensified and the patient s temperature increased to 38.4 c .
the patient continued to exhibit hypotension , breathing difficulties , and spo2 of 90% or lower . an intraabdominal hemorrhage or formation of a pelvic abscess
was suspected after 32 hours of initial presentation , and the decision was made to perform an emergency laparotomy .
blood test results just prior to surgery were wbc count of 700/l , hb of 7.8 g / dl , plt count of 10.2  104/l , crp of 25.5 mg / dl , bun of 35.2 mg / dl , and creatinine of 2.12 mg / dl .
a large volume of ascites that resembled pus and general peritonitis were manifested in the peritoneal cavity .
other than uterine fibroids , lesions were not evident in the uterus , ovaries , or fallopian tubes .
the intestines were somewhat edematous , but no gastrointestinal problems , such as a gastrointestinal perforation and cholangitis , were noted .
1 ) . peritoneal lavage and drainage was performed along with a partial omentectomy and an appendectomy .
a peritoneal drain was placed and the abdomen was closed . while she was managed on a ventilator , 1 g of meropenem three times a day ( tid ) was added to azm .
the total volume of transfusions from surgery until discharge from the intensive care unit was 24 units of packed red blood cells , 22 units of fresh frozen plasma , and 60 units of platelets , continuous hemodiafiltration was performed , direct hemoperfusion was performed with a polymyxin b - immobilized column , an immunoglobulin preparation was administered , and hemodynamics was managed with continuous intravenous infusion of noradrenaline .
blood test results about 10 hours after surgery revealed the following : wbc count of 21,000/l , hb of 10.1 g / dl , plt count of 4.6  104/l , crp of 21.5 mg / dl , bun of 36.4 mg / dl , creatinine of 2.15 mg / dl , total bilirubin of 1.83 mg / dl , aspartate aminotransferase of 699 iu / l , alanine aminotransferase of 226 iu / l , fibrin degradation product of 93.3 g / ml , fibrinogen of 204 mg / dl , and prothrombin time of 24.6 seconds .
chest x - rays revealed infiltrated in the fields of both lungs , and ards , dic , and multiple organ failure were manifested . on day 4 after initial presentation ,
gas was isolated in an intraoperative peritoneal fluid culture , resulting in the diagnosis of stss .
the bacteria isolated in blood cultures , vaginal culture , or urine culture after administration of azm were not the same .
in addition , 900 mg of clindamycin tid and four million units of penicillin g once a day ( sid ) were administered . on day 4 after initial presentation , a rash resembling erythema developed primarily in both lower extremities and necrosis developed in the distal extremities due to poor peripheral circulation .
histopathology indicated necrotic tissue , and gram staining revealed gram - positive bacteria ( fig .
stss is a reemerging infectious disease that was initially reported in the us in 1987.1 stss has a fatality rate of 40% or higher.1 gas infection has long been known to cause pharyngitis , tonsillitis , scarlet fever , and sequelae , such as rheumatic fever and acute glomerulonephritis .
initial manifestations of stss include pain in the extremities , swelling , a fever , and hypotension ; soon after developing stss ( within 2448 hours ) , it can cause acute renal failure , ards , dic , and soft tissue necrosis , and it can even lead to death.2 the virulence factors of gas are far more varied than those of other bacteria , and the various exotoxins produced by gas stimulate cytokine release and act as superantigens.3 a study of stss isolates has suggested that specific genetic mutations allow gas to evade elimination by the host s neutrophils , causing a highly pathogenic disease characterized by fulminant infection.4 according to a systematic review of 32 cases of primary peritonitis due to stss , the median age for the development of stss was 38 years ( range : 2387 years ) , female patients outnumber male patients at a ratio of 4:1 , and 91% of patients were healthy with no underlying illness.5 according to the same systematic review , 16% of patients developed stss from an ascending infection originating from vagina , 6% of patients developed it from pharyngitis , 9% of patients developed it from a droplet infection , and 69% of patients developed it via an unknown route.5 in the current case , the patient was transported to the emergency department 14 hours after developing symptoms .
when the patient was seen , she had a slight fever , and her vital signs stabilized , so stss would have been an unlikely differential diagnosis .
there is a room to discuss the appropriateness of performing an emergency laparotomy , while the patient had a wbc count as low as 700/l .
peritoneal fluid was tested for bacteria about 70 hours after initial presentation , and the results revealed the presence of gas .
this approach saved the patient s life , so performing surgery was the correct choice in this case .
routes of infection have often cited an ascending infection originating from vagina.5 in the current case , infection occurred during menses , and a pedunculated tumor stained positive for gram - positive bacteria , so the patient presumably had an ascending infection originating from vagina .
if a patient complaining of lower abdominal pain has a fever or elevated inflammatory markers , further testing ( which includes vaginal culture ) must be performed prior to the administration of an antibiotic .
a recent report demonstrated a 6-year - old girl who initially presented with presumed viral gastrointestinal infection for a week and later developed catastrophic primary peritonitis and septic shock requiring resuscitation and emergency exploratory laparotomy due to group a streptococci.6 the incidence of stss has increased over the past few years , so stss must be kept in mind as potential diagnosis if a patient has abdominal symptoms that abruptly worsen .
 purposewe encountered a case where an infection with group a streptococcus ( gas ; ie , streptococcus pyogenes ) initially caused primary peritonitis and then subsequently caused streptococcal toxic shock syndrome . 
 the patient s life was likely saved by an emergency laparotomy followed by extensive peritoneal lavage and drainage.case presentationa 40-year - old woman was admitted to the emergency department for lower abdominal pain and numbness in the extremities . 
 she presented with systemic inflammatory response syndrome . 
 an emergency laparotomy was performed , and ascites that resembled pus and general peritonitis were noted . 
 peritoneal lavage and drainage were performed , and gas was isolated from peritoneal fluid . 
 gram staining of cervical polyp specimens revealed gram - positive bacteria.conclusionsthe patient was diagnosed with streptococcal toxic shock syndrome due to an ascending gas infection originating from vagina . 