Intrauterine device as source of pneumococcal intra-abdominal infection and small-bowel obstruction

Pneumococcal peritonitis in adults is a rare disease, occurring mainly in patients with liver cirrhosis or nephrotic syndrome [1, 2]. Although pneumococcus is not considered part of the normal flora of the female genital tract, it has been a cause of infection in the female genital tract and of peritonitis, especially in young women [2–5]. We report a case of pneumococcal peritonitis presenting as a small-bowel obstruction in a young woman with an intrauterine contraceptive device (IUD). A 38-year-old previously healthy woman was admitted to the emergency room with diffuse abdominal pain, vomiting and diarrhea, which began 3 days prior to admission. On physical examination she had a pulse rate of 130 beats per minute, blood pressure of 120/80 mmHg, and a fever of 37.3°C. Her abdomen was slightly distended and soft with diffuse tenderness, but no peritoneal signs were evident. Laboratory results were normal except for leukocytosis (21×10 l), a creatinine level of 177 μmol/l, and a blood urea nitrogen level of 13.2 mmol/l. The initial diagnosis made in the emergency room was acute gastroenteritis, and the patient was treated with intravenous fluids. Twenty hours later (or 4 days after the onset of symptoms), the diarrhea ceased, but the patient remained toxic, with crampy abdominal pain and vomiting. Her abdomen became much more distended and tender. A gastric catheter was inserted, and a large volume of feculent fluid was drained. A diagnosis of small-bowel obstruction was made based on the findings of an abdominal radiograph and subsequent computed tomography scan of the abdomen. During surgery, some serous fluid in the abdomen and extremely distended loops of small-bowel covered with a thick yellowish exudate were observed. The terminal ileum was fixed in the pouch of Douglas with adhesion to the pelvic peritoneum. Following release and extraction of purulent fluid, a slightly edematous uterus and fallopian tubes were observed along with normal ovaries. After complete extraction of abdominal fluid and free particles of exudate, the laparotomy wound was closed. The IUD was removed immediately after the operation, and abdominal fluid, exudates and the IUD were sent for culture. Intravenous administration of ampicillin, gentamicin and metronidazole, which had been started prior to surgery, was continued. The following day, culture of abdominal fluid, exudates and the IUD all yielded growth of Streptococcus pneumoniae. In view of the severity of the infection and the possibility of polymicrobial infection, treatment was changed to intravenous amoxicillin-clavulanate alone, followed by oral amoxicillin-clavulanate for 1 week. The patient had an uneventful postoperative period and was discharged from the hospital on postoperative day 7. Three months following surgery, she remained well. Peritonitis can be classified as primary or secondary, based upon how the causative organism gained access to the peritoneal cavity; i.e., without loss of bowel wall integrity (primary) or through loss of bowel mucosal wall integrity (secondary) [1]. Primary peritonitis is usually caused by gram-negative bacilli reaching the peritoneal cavity either by a process of translocation from the bowel or, occasionally, by hematogenous spread from a distant infectious site. Secondary peritonitis is usually characterized by polymicrobial infection reflecting the nature of normal intestinal flora. B. Rudensky (*) Department of Clinical Microbiology, Shaare Zedek Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, P.O. Box 3235 Jerusalem, 91031, Israel e-mail: rudensky@szmc.org.il Tel.: +972-2-6555123 Fax: +972-2-6555857