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Nephrotic syndrome presenting as primary peritonitis in a male adolescent A 16-year-old man with no relevant past medical history was admitted with sudden-onset severe generalized abdominal pain. On examination, he was tachycardic, tachypnoeic and febrile (39.7°C), with generalized guarding and percussion tenderness. Blood tests revealed a leucocytosis (white cell count 17.0 × 109/L), and a low serum albumin (90%) effacement of epithelial foot processes, consistent with minimal change nephropathy.
loss of immunoglobulins (especially IgG)5 and important factors in the complement pathway (especially factors B and D).6 The body’s ability to synthesize new specific antibodies is also impaired in nephrotic syndrome.7 Most cases are in patients with a pre-existing diagnosis of nephrotic syndrome, who are often further immunosuppressed by the administration of corticosteroid. This may also be a contributory factor. Various studies have reported common organisms implicated in primary peritonitis associated with nephrotic syndrome, with Streptococcus pneumonia, alpha-haemolytic Streptococcus and Escherichia coli being among the commonest.8 We could only find two published cases (from 1978 and 1979) showing group B Streptococcus as the causative organism.9,10 This case demonstrates a rare but important cause of peritonitis in adults. Although the patient is 16 years old and would be considered by many an adolescent rather than an adult, he is beyond the expected age range for this condition, and old enough that he would present to an adult surgical unit rather than a paediatric hospital. Despite the rarity of this condition in adults, it should be suspected and investigated for in the setting of unexplained low serum albumin and proteinuria. An early diagnosis is important to avoid the need for laparotomy, and institute conservative treatment with antibiotics. Appropriate broad spectrum antibiotics based on local microbiology advice is important given the variation in causative organisms seen. Appropriate attention must be paid to investigating the underlying
1. Lasry F, Badre A, Naim A, Oumil M, Khalifa HH. Primary peritonitis in children with nephrotic syndrome. Nephrol. Ther. 2005; 1: 311–4. 2. Hingorani SR, Weiss NS, Watkins SL. Predictors of peritonitis in children with nephrotic syndrome. Pediatr. Nephrol. 2002; 17: 678–82. 3. Ruiz S, Soto S, Rodado R, Alcaraz F, Lopez Guillen E. Spontaneous bacterial peritonitis as form of presentation of idiopathic nephrotic syndrome in a black adult. An. Med. Interna. 2007; 24: 442–4. 4. Alwadhi RK, Matthew JL, Rath B. Clinical profile of children with nephrotic syndrome not on glucocorticoid therapy, but presenting with infection. J. Paediatr. Child Health 2004; 40: 28–32. 5. Giangiacomo J, Cleary TG, Cole BR, Hoffsten P, Robson AM. Serum immunoglobulins in the nephrotic syndrome. A possible cause of minimal change nephrotic syndrome. N. Eng. J. Med. 1975; 293: 8–12. 6. McLean RH, Forsgren A, Björkstén B, Kim Y, Quie PG, Michael AF. Decreased serum factor B concentration associated with opsonisation of Escherichia coli in the idiopathic nephrotic syndrome. Pediatr. Res. 1977; 11: 910–6. 7. Spika JS, Halsey NA, Fish AJ et al. Serum antibody response to pneumococcal vaccine in children with nephrotic syndrome. Pediatrics 1982; 69: 219. 8. Uncu N, Bulbul M, Yildiz N et al. Primary peritonitis in children with nephrotic syndrome: results of a 5-year multicentre study. Eur. J. Pediatr. 2010; 169: 73–6. 9. Kaleida PH, Starr SE. Group B streptococcal peritonitis in a child with the nephrotic syndrome. J. Med. Assoc. Ga. 1978; 67: 721–2. 10. Bannatyne R, Stringel G, Simpson J. Spontaneous peritonitis due to group B streptococci. Can. Med. Assoc. J. 1979; 121: 442–3.
Kenneth Boyd, MBChB David Mitchell, MBBS Andreas L. Lambrianides, MBBS, FRACS General Surgery, Redcliffe Hospital, Brisbane, Queensland, Australia doi: 10.1111/ans.12774
© 2014 Royal Australasian College of Surgeons
Nephrotic syndrome presenting as primary peritonitis in a male adolescent A 16-year-old man with no relevant past medical history was admitted with sudden-onset severe generalized abdominal pain. On examination, he was tachycardic, tachypnoeic and febrile (39.7°C), with generalized guarding and percussion tenderness. Blood tests revealed a leucocytosis (white cell count 17.0 × 109/L), and a low serum albumin (90%) effacement of epithelial foot processes, consistent with minimal change nephropathy.
loss of immunoglobulins (especially IgG)5 and important factors in the complement pathway (especially factors B and D).6 The body’s ability to synthesize new specific antibodies is also impaired in nephrotic syndrome.7 Most cases are in patients with a pre-existing diagnosis of nephrotic syndrome, who are often further immunosuppressed by the administration of corticosteroid. This may also be a contributory factor. Various studies have reported common organisms implicated in primary peritonitis associated with nephrotic syndrome, with Streptococcus pneumonia, alpha-haemolytic Streptococcus and Escherichia coli being among the commonest.8 We could only find two published cases (from 1978 and 1979) showing group B Streptococcus as the causative organism.9,10 This case demonstrates a rare but important cause of peritonitis in adults. Although the patient is 16 years old and would be considered by many an adolescent rather than an adult, he is beyond the expected age range for this condition, and old enough that he would present to an adult surgical unit rather than a paediatric hospital. Despite the rarity of this condition in adults, it should be suspected and investigated for in the setting of unexplained low serum albumin and proteinuria. An early diagnosis is important to avoid the need for laparotomy, and institute conservative treatment with antibiotics. Appropriate broad spectrum antibiotics based on local microbiology advice is important given the variation in causative organisms seen. Appropriate attention must be paid to investigating the underlying
1. Lasry F, Badre A, Naim A, Oumil M, Khalifa HH. Primary peritonitis in children with nephrotic syndrome. Nephrol. Ther. 2005; 1: 311–4. 2. Hingorani SR, Weiss NS, Watkins SL. Predictors of peritonitis in children with nephrotic syndrome. Pediatr. Nephrol. 2002; 17: 678–82. 3. Ruiz S, Soto S, Rodado R, Alcaraz F, Lopez Guillen E. Spontaneous bacterial peritonitis as form of presentation of idiopathic nephrotic syndrome in a black adult. An. Med. Interna. 2007; 24: 442–4. 4. Alwadhi RK, Matthew JL, Rath B. Clinical profile of children with nephrotic syndrome not on glucocorticoid therapy, but presenting with infection. J. Paediatr. Child Health 2004; 40: 28–32. 5. Giangiacomo J, Cleary TG, Cole BR, Hoffsten P, Robson AM. Serum immunoglobulins in the nephrotic syndrome. A possible cause of minimal change nephrotic syndrome. N. Eng. J. Med. 1975; 293: 8–12. 6. McLean RH, Forsgren A, Björkstén B, Kim Y, Quie PG, Michael AF. Decreased serum factor B concentration associated with opsonisation of Escherichia coli in the idiopathic nephrotic syndrome. Pediatr. Res. 1977; 11: 910–6. 7. Spika JS, Halsey NA, Fish AJ et al. Serum antibody response to pneumococcal vaccine in children with nephrotic syndrome. Pediatrics 1982; 69: 219. 8. Uncu N, Bulbul M, Yildiz N et al. Primary peritonitis in children with nephrotic syndrome: results of a 5-year multicentre study. Eur. J. Pediatr. 2010; 169: 73–6. 9. Kaleida PH, Starr SE. Group B streptococcal peritonitis in a child with the nephrotic syndrome. J. Med. Assoc. Ga. 1978; 67: 721–2. 10. Bannatyne R, Stringel G, Simpson J. Spontaneous peritonitis due to group B streptococci. Can. Med. Assoc. J. 1979; 121: 442–3.
Kenneth Boyd, MBChB David Mitchell, MBBS Andreas L. Lambrianides, MBBS, FRACS General Surgery, Redcliffe Hospital, Brisbane, Queensland, Australia doi: 10.1111/ans.12774
© 2014 Royal Australasian College of Surgeons
