primary peritonitis constitutes less than 1% of peritonitis and spontaneous bacterial peritonitis usually occurs in patients with comorbid conditions . in absence of comorbid conditions , including liver cirrhosis , immunosuppression , or nephrotic syndrome , primary peritonitis is rare , particularly in cases of healthy young subjects . primary peritonitis due to s. pyogenes is an unusual condition because streptococcus pyogenes usually causes pharyngitis , erysipelas , and necrotizing fasciitis . in this report , we present the first case to the best of our knowledge of primary peritonitis due to s. pyogenes in korea . 29-yr - old woman presented to the emergency room with lower abdominal pain on april 20 , 2011 . she had no travel history and had not taken any medication . on physical examination , she was alert and cooperative . her body temperature was 38 , blood pressure 80/60 mmhg , pulse 113 beats per minute , respiratory rate 20 breaths per minute , and oxygen saturation 99% while breathing ambient air . results of gynecological examination from gynecologists were also normal and no history of abnormal vaginal discharge was known . initial blood tests showed leukocyte count of 6,248/l , platelet count of 133,000/l , c - reactive protein ( crp ) level of 12.36 mg / dl , and procalcitonin level of 36.9 ng / ml . renal and liver function tests , clotting screen , and arterial blood gas were all within normal range . abdominal ct revealed edematous swelling of the intestinal wall and ascites with peritoneal enhancement suggesting peritonitis ( fig . as physical , laboratory , and radiologic findings suggested acute peritonitis , laparoscopy searching for etiology was performed . purulent ascites was found in the pelvic cavity but both ovaries and fallopian tubes were intact ( fig . there were no intra - abdominal abnormalities such as bowel perforation , appendicitis , or necrosis . reports of blood culture , ascites culture , and cervical swab culture showed gram - positive cocci . initial empiric antibiotics ( ampicillin / sulbactam 2 g/1 g every 6 hr ) switched to penicillin g ( 300 mu every 4 hr ) and metronidazole ( 500 mg every 8 hr ) . primary peritonitis caused by streptococcus pyogenes is uncommon and rarely diagnosed in a healthy person without underlying diseases . spontaneous bacterial peritonitis due to streptococcus pyogenes in a cirrhotic child was reported in korea ( 1 ) but s. pyogenes peritonitis in a healthy person has not yet been reported in korea . therefore , this is the first case of primary peritonitis due to streptococcus pyogenes in a healthy person in korea . it is reported that most instances of spontaneous primary peritonitis are due to streptococcus pneumoniae ( 2 ) . there are a few cases describing s. pyogenes peritonitis in healthy women , even though the entry site of s. pyogenes in peritonitis is not uncertain . ( 3 ) suggested that in some women , s. pyogenes in peritonitis may be via the genital tract , despite lack of gynecological symptoms even though many studies have shown an absence of s. pyogenes as normal flora of the female genital tract . the hematogenous route may be an alternate , possibly from pharyngeal or cutaneous primary sites ( 3 ) . in this case , ascending genital infections was considered to be the entry site because of the positive cervical swab culture . the majority of primary peritonitis is diagnosed retrospectively when secondary causes are excluded after surgical approach ( 4 ) . preference for laparoscopy or laparotomy is established by the surgeon 's choice and laparotomy is predominantly performed in previous cases . however , farooq and ammori ( 5 ) claimed that laparoscopy could be used as a diagnostic tool in the management of generalized peritonitis . we chose laparoscopy as a diagnostic tool in this case because no significant abnormalities suggesting secondary peritonitis were found on abdominal ct . the severe infection of s. pyogenes requires a high index of suspicion , prompt diagnosis , and rapid initiation of appropriate antibiotics ( 6 ) . in this case , reports of blood culture , abdominal ascites culture , and cervical swab culture showed gram - positive cocci , so ampicillin / sulbactam was applied . after final result of culture confirmed s. pyogenes , antibiotics were switched to penicillin g and metronidazole . it is reported that some s. pyogenes serotypes are more commonly associated with invasive group a streptococcal disease than other gas isolates ( 7 - 9 ) . we did not obtain the serotype of s. pyogenes , so further study on s. pyogenes serotypes in primary peritonitis is required . in summary , we report the first case of primary peritonitis in korea in a young , healthy woman due to s. pyogenes . the port of entry was thought to be via the genital tract , despite no local symptoms . laparoscopy as a diagnostic tool was performed in this case and we recommend laparoscopy over laparotomy when no significant abnormalities suggesting secondary peritonitis are seen on abdomen computed tomography . an appropriate diagnostic approach and prompt antibiotic therapy is essential in primary gas peritonitis .
we describe the first case of primary peritonitis in korea of a healthy person due to streptococcus pyogenes . in the absence of comorbid conditions , such as liver cirrhosis , immunosuppression , or nephrotic syndrome , 
 primary peritonitis is uncommon in a young healthy woman . 
 abdomen computed tomography revealed ascites in the lower abdomen and peritoneal enhancement suggesting peritonitis . in diagnostic laparoscopy , purulent ascites was found in the pelvic cavity but both ovaries and fallopian tubes were intact . there were no intra - abdominal abnormalities such as bowel perforation , appendicitis , or necrosis . 
 the reports of blood culture , ascites culture , and cervical swab culture confirmed s. pyogenes . 
 after use of antibiotics , the patient was cured and discharged without sequelae .