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Letters to the Editor

Spontaneous Bacterial Peritonitis Caused by Nontypeable Haemophilus influenzae in a Previously Healthy Child

Dimopoulou, Anastasia MD; Dimopoulou, Dimitra MD; Christianakis, Efstratios MD; Bourikas, Dimitrios MD; Alexandrou, Ioannis MD; Samonis, George MD

Author Information
The Pediatric Infectious Disease Journal: June 2013 - Volume 32 - Issue 6 - p 704
doi: 10.1097/INF.0b013e3182869657
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To the Editors:

Spontaneous bacterial peritonitis (SBP) is an infection of the peritoneum without obvious intra-abdominal cause.1 Most episodes of SBP develop in patients with cirrhosis, but has also been observed in congestive heart failure, nephrotic syndrome, fulminant hepatic failure and alcoholic and viral hepatitis.2 SBP developing in healthy individuals is rare.2Haemophilus influenzae is a rare cause of SBP in normal children and has been assumed to originate from a respiratory source.3 Only 3 cases of SBP caused by H. influenzae have been reported.4–6 However, SBP caused by nontypeable H. influenzae biotype ІІ in otherwise healthy child has never been reported.

A 13-year-old previously healthy boy presented to the emergencyroom with 8 days of abdominal pain, fever, diarrhea and vomiting. He reported recent symptoms of upper respiratory tract infection. His temperature was 38°C, the abdomen was tense and tender with signs of peritoneal inflammation. The white blood cell count was 26.9 K/μL (80.8% segmented cells). C-reactive protein was 24.6 mg/L. Ultrasound showed a localized inflammatory mass in the right lower abdomen. The child was considered to have advanced appendicitis taken to surgery.

He received preoperatively intravenous amoxicillin and clavulanic acid, metronidazole and netilmicin. Intraoperatively, the abdominal cavity contained 1000 mL of purulent peritoneal fluid, which was Gram stained and cultured for aerobic and anaerobic organisms. The appendix was normal, whereas the omentum was inflamed and edematous with ischemic lesions distally. Appendectomy was performed, and the ischemic portion of the omentum was removed. The peritoneal cavity was irrigated with isotonic crystalloid solution until the returns were clear, and the wound was closed primarily. There were no surgical complications. Histopathology of the appendix and the omentum was normal.

The peritoneal fluid culture grew a nontypeable H. influenzae, biotype ІІ, susceptible to amoxicillin and clavulanic acid. The diagnosis of SBP due to H. influenzae was established. The patient received 10 days of antibiotic therapy and recovered completely.

The signs and symptoms of SBP are nonspecific. Approximately 10% of the patients are asymptomatic.1 The diagnosis is established by examination of the ascitic fluid. The polymorphonuclear leukocyte count in the fluid exceeds 250 cells/mm³, and peritoneal cultures yield the pathogen.1 Empiric antimicrobial therapy is started, as soon as infection is suspected.2

Preoperatively, diagnosis of SBP in previously healthy children is difficult because of the suspicion of secondary peritonitis undergo laparotomy. The present report demonstrates that SBP due to H. influenzae, although a rare condition in children with no underlying disease, should be considered as a possibility in children with acute abdominal pain, especially if following infection of the respiratory tract. Early diagnosis of SBP, caused by H. influenzae in otherwise normal children, is essential for effective treatment and improved outcome.

Anastasia Dimopoulou, MD

Department of Pediatric Surgery

Children’s Hospital of Penteli

Athens, Greece

Dimitra Dimopoulou, MD

Department of Internal Medicine

University Hospital of Heraklion

Crete, Greece

Efstratios, Christianakis, MD

Dimitrios Bourikas, MD

Ioannis Alexandrou, MD

Department of Pediatric Surgery

Children’s Hospital of Penteli

Athens, Greece

George, Samonis, MD

Department of Internal Medicine

University Hospital of Heraklion

Crete, Greece

REFERENCES

1. Such J, Runyon BA. Spontaneous bacterial peritonitis. Clin Infect Dis. 1998;27:669–674; quiz 675
2. Sheer TA, Runyon BA. Spontaneous bacterial peritonitis. Dig Dis. 2005;23:39–46
3. Musher DM, Nichol AC, Rueda AM. Nontypeable Haemophilus influenzae as a cause of spontaneous bacterial peritonitis. J Clin Microbiol. 2006;44:2304–2306
4. Chang MJ, Controni G. Primary peritonitis due to Haemophilus influenzae type b in a previously healthy child. J Clin Microbiol. 1983;18:725–726
5. Gorski J, Ingall D, Yogev R. Primary peritonitis associated with Hemophilus influenzae bacteremia in a normal child. Clin Pediatr (Phila). 1983;22:183
6. Moore JL, Ricketts RR. Hemophilus influenza primary peritonitis in an infant: report of a case. J Pediatr Surg. 1984;19:594–595
© 2013 Lippincott Williams & Wilkins, Inc.