Sometimes hoofbeats mean Zebras!

Patient was a 37y/o Woman, presented with fevers and 3 days of diarrhoea and vomiting. Had been seen day before by GP and felt likely Gastro to return if worsens.

Notes report patient was not too bad, generalised abdominal pain, soft but slightly tender abdomen. Bloods sent, stool sent, urine nil. For review in morning after IV fluids and analgesia.

I arrived to medical ward for round following morning. Patient was clearly worse and not simple gastro. Febrile 39.2C, P 120 Bp 97/45 Guarded peritonitic lower abdomen.  Blood cultures taken. Started on Cefuroxime and Metronidazole. Called the surgeon who said “sounds like I should come and review, might not be for me. Please arrange a CT”

CT showed:

Report: Free fluid, uncertain cause. Prominent distal ilium and    
appendix, but non-specific. Is there any clinical
indication of inflammatory bowel disease or other small    
bowel inflammatory cause? Appendicitis remains in the      
differential.      
Ectopic pregnancy also remains in the differential. Has    
beta-hCG been performed?

Bloods: WCC 26, Neuts 24 CRP>350 Cr 150 Hcg<5

Proceeded to theatre for laparoscopy, which found: Green, purulent fluid and diffuse peritonitis with some inflammatory adhesions. Swabs/fluid sent. Unable to find a clear cause no obvious perforation. appendix normal.

Following day call from Lab, fluid growing pure Strep A. Was like Is this the right patient, shouldnt you be calling with E.coli or Klebsiella?

Then I went searching and found some case reports.

Apparently Group A Strep is a rare cause of peritonitis, mostly in healthy women. Its thought to be related to GU spread but no-ones certain. Most, like our patient end up going to theatre as its pretty much impossible for the surgeons not to operate and diagnosis often following labs.

Patient doing well, WCC, Markers falling. Nil pain, up and about and out the door.

So that was the Zebra that turned up when I heard hoofbeats at work this week.

Refs:

http://ajcc.aacnjournals.org/content/19/5/454.full

http://www.ncbi.nlm.nih.gov/pubmed/10777203