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A Rare Case of Secondary Streptococcus pyogenes Peritonitis in a Patient With Cirrhosis

Philippou, Alicia MD1; Bowman-Zamora, Chip MD, MPH1; Ezaz, Ghideon MD, MPP2

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doi: 10.14309/crj.0000000000000761
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A 42-year-old woman with autoimmune hepatitis with decompensated cirrhosis and ascites presented with 8 days of worsening abdominal pain. She was afebrile with diffuse abdominal tenderness without rebound or guarding and a large umbilical hernia with overlying skin breakdown. Diagnostic paracentesis produced a protein 5.2 g/dL, glucose < 5 mg/dL, lactate dehydrogenase 14,252 U/L, and a white blood cell count of 59,200/μL with 83% polymorphonuclear cells. Cultures grew Streptococcus pyogenes. Imaging showed large ascites communicating with a loculated fluid collection in the umbilical hernia (Figure 1). The loculated collection drained purulent fluid positive for moderate Gram-positive cocci in chains and clusters. Despite 2 weeks of ceftriaxone (2 g) and metronidazole (500 mg), clinical peritonitis with fevers persisted. Repeat paracentesis showed an increase in white blood cells to 82,760/μL. Laparoscopy with peritoneal washout was performed with removal of 6 L of purulent fluid and lysis of dense adhesions and fibrinous exudate (Figure 2). Pathology demonstrated acute fibrinous inflammatory exudate with dense fibrous tissue. Antibiotics were broadened to piperacillin-tazobactam (3.375 g) with improvement, and she was discharged on cefpodoxime (200 mg).

Figure 1.:
Abdominal and pelvic computed tomography with large volume ascites and loculated fluid collection in the umbilical hernia.
Figure 2.:
Dense adhesions and fibrinous exudate is seen throughout the peritoneum on laparoscopy.

Secondary peritonitis in patients with cirrhosis is uncommon and has a high mortality (53.8%) with appropriate surgical management, so rapid differentiation from primary spontaneous bacterial peritonitis is paramount.1 Runyon's criteria can be used and require 2 of 3 criteria: ascitic fluid protein >1 g/dL, glucose <50 mg/dL, and lactate dehydrogenase greater than normal serum's upper limit. Ascitic fluid growing multiple organisms and clinical failure to respond to appropriate antibiotics are other clues in establishing the diagnosis.2

S. pyogenes peritonitis is rare, limited to case series and reports of individuals without previous underlying liver disease, peritoneal dialysis, or pelvic inflammatory disease. A case series of available evidence until March 2018 identified 30 published cases of S. pyogenes peritonitis in previously healthy individuals. Given female predominance (75%), a hypothesized portal of entry was translocation from the vaginal tract.3 There are 240 cases of culture-positive peritonitis in patients with cirrhosis contained only 2 cases of S. pyogenes, although without case details.4 One case report documented S. pyogenes peritonitis in a patient with cirrhosis with umbilical hernia rupture.5 Given the similarity in the examination, this was considered the likely portal of entry in our patient.

This case highlights the challenges in managing secondary peritonitis in patients with cirrhosis, including the importance of early differentiation between primary and secondary peritonitis and successful stepwise management.


Author contributions: A. Philippou and C. Bowman-Zamora wrote the manuscript. G. Ezaz edited the manuscript and is the article guarantor.

Financial disclosure: None to report.

Previous presentation: This case was presented at the New York ACP poster presentation; April 8, 2021; Virtual.

Informed consent was obtained for this case report.


1. Soriano G, Castellote J, Alvarez C, et al. Secondary bacterial peritonitis in cirrhosis: A retrospective study of clinical and analytical characteristics, diagnosis and management. J Hepatol. 2010;52(1):39–44.
2. Wiest R, Schoelmerich J. Secondary peritonitis in cirrhosis: ‟oil in fire.” J Hepatol. 2010;52(1):7–9.
3. Johnson M, Bartscherer A, Tobin E, Tafen M. Streptococcus pyogenes peritonitis: A rare, lethal imitator of appendicitis. BMJ Case Rep. 2019;12(9):e23049.
4. Dupeyron C, Campillo B, Mangeney N, Richardet JP, Leluan G. Changes in nature and antibiotic resistance of bacteria causing peritonitis in cirrhotic patients over a 20 year period. J Clin Pathol. 1998;51(8):614–6.
5. Hecker MT, Donskey CJ. Secondary peritonitis due to Staphylococcus aureus resulting from a ruptured umbilical hernia, Infect Dis Clin Pract. 2002;11:147–8.
© 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.