A mystery that takes in the belly (solution)

Let us find this young woman who presents peritonitis without a focus obvious associated with bilateral basal pneumonia. Moreover, association which directs towards a rare, but well documented diagnosis: primitive or spontaneous peritonitis (1). Nevertheless, This nosological entity. However, defined as an infectious process involving the peritoneal cavity without septic origin or intra-abdominal inflammatory, neither visceral perforation, nor penetrating abdominal wound, represents less than 1 % of all cases of peritonitis.

Converging diagnostic arguments

Several elements argue in favor of this diagnosis. Moreover, First of all. Nevertheless, the exhaustive surgical exploration has shown no obvious cause of peritonitis: appendix, ovaries, tubes and gallbladder presented a normal aspect. For example, Imaging confirmed the absence of pneumoperitoneum and made it possible to dismiss a digestive perforation.

Basal bilateral pneumopathy is an element of pathophysiological understanding. Furthermore, In primitive peritonitis, peritoneal contamination takes place hematogenic from a distant infectious hearth, mystery takes belly (solution) conventionally ENT, pulmonary or gynecological. More rarely, the lymphatic route, trans-diaphragmatic contamination or intestinal bacterial translocation are incriminated.

In this young patient, the evolution has confirmed the relevance of the therapeutic strategy. Bacteriological examinations of peritoneal fluid and hemocultures have remained sterile. The postoperative evolution was favorable. the patient left the hospital on the fifth postoperative day with a relay by oral antibiotic therapy for five days.

The negativity of bacteriological samples. far from invalidating the diagnosis, is part of the usual table of this pathology where the infectious investigation can remain negative. This particularity can be explained by the difficulty of isolation of certain germs. by the effect of early antibiotic therapy.

Understand primitive peritonitis

Primitive peritonitis usually affects patients with specific risk factors: hepatic cirrhosis with ascites. nephrotic syndrome, lupus or peritoneal dialysis. However, it can occur in young subjects without history, as in this observation.

Bacterial inoculation is generally Mono-Microbial, mainly involving mystery takes belly (solution) pneumococcus and beta-hemolytic streptococcus of group A (2). These germs. of respiratory origin, explain the frequent association with pulmonary manifestations, justifying the systematic search for an extra-abdominal infectious home.

Diagnostic. therapeutic challenges

The diagnosis of primitive peritonitis remains a diagnosis of elimination, established retrospectively after exclusion from all other causes of peritonitis by imaging and especially by surgical exploration. Thus, surgical management is often essential, even if the treatment is fundamentally medical.

The therapeutic strategy systematically combines peritoneal wash, by laparotomy or laparoscopy, and large spectrum probabilistic antibiotic therapy. The “principle” appendectomy carried out in this patient is part of the diagnostic elimination logic. although the appendix was macroscopically normal.

The favorable evolution under medico-surgical treatment retrospectively confirms the diagnosis. underlines the importance of early management to avoid evolution towards multivisceral failure, a formidable complication of this pathology.

Clinical lessons

This case illustrates the diagnostic difficulties of primitive peritonitis in young adults without risk factor. He mystery takes belly (solution) underlines the importance of systematically looking for an extra-abdominal infectious home before any peritonitis without obvious cause. recalls that surgical exploration remains essential in this context of diagnostic uncertainty.

Primitive peritonitis. although rare, must be mentioned before any peritonitis without an identifiable abdominal household, particularly in the presence of an extra-abdominal infection concomitant.