Streptococcal peritonitis in a patient with Hodgkin's disease and an intrauterine contraceptive device

288

Communications

September J Obstrt.

in brief .2n1.

a lymphoblastic lymphosarcoma, filtrating and partially replacing the bowel wall (Fig. 2). The was ulcerated. Although leiomyosarcoma, other malignant tumors

extensively inall layers of luminal surface

lymphosarcoma, of the small bowel

Streptococcal peritonitis with Hodgkin’s disease intrauterine contraceptive

and ac-

ALFRED

N.

ROBERT

F.

PETER

H.

EDWARD W.

WE

M.D. M.D.

BERCZELLER, L.

M.D.

AMOROSI,

M.D.

N.

M.D.

GRIER,

of Surgery, Obstetrics and and Medicine, New York Medical Center, New York,

RECENTLY

developed

M.D

HARRIS,

PORGES,

ROBSON

Departments Gynecology, University New York

in a patient and an device

CULLIFORD,

MATTHEW

count for only 4 per centl, 6, a, gt I1 of all gastrointestinal’ malignancies, much confusion may attend their diagnosis for, as a group, they have an unusual tendency to mimic other disease states. They may exhibit clinical patterns suggestive of polyarteritis nodosa,s Addison’s disease,5 the malabsorption syndrome,5 and the carcinoid syndrome. r, 6, 8 Acute manifestation+ rs like intussusception, obstruction, and perforation may also supervene. Most often, however, the characteristic presentation of leiomyosarcoma and lymphosarcoma of the small bowel is limited to features like abdominal paina, 4, i, 13 a mass in the abdomeq6, 8~ 121 13 severe anemia,22 +*, lo and

T.

15, lYi3 Gynecol

streptococcal

cared for peritonitis

a patient 5 weeks

who fol-

weight loss.2, a, *, 9 Other specific gastrointestinal symptoms are usually lacking. Quite clearly, this symptom complex may not be distinguishable from that of primary ovarian cancer. In this situation, mistaking an intestinal leiomyosarcoma or lymphosarcoma for a malignant ovarian tumor

lowing staging splenectomy for Hodgkin’s disease and 2 months following insertion of an intrauterine contraceptive device. This case is being

would seem unavoidable without a special awarness of the close symptomatic similarities between these 2 tumor groups. When clinical examination cannot resolve one’s doubt, a small bowel x-ray series may be of help.

The patient (U.H. 281354) was a 26-year-old white woman who noted lymphadenopathy in the left supraclavicular region during the third month of her first pregnancy. Biopsy revealed Hodgkin’s disease of the nodular scierosing type. The patient had no systemic symptoms and no other apparent areas of involvement. The disease was tentatively staged clinically as IA, pending a full abdominal evaluation, During the remaining months of pregnancy, treatment consisted of 4,000 rads to the mantle area. The patient had a precipitate delivery at 34 weeks of a well-developed male infant weighing 4 pounds, 14 ounces. Following delivery, a full radiologic study, including lymphangiography, was normal. Skin tests revealed that the patient was not anergic. A Lippes Loop* was inserted 5 weeks after delivery. Two months after delivery, the patient had a splenectomy and para-aortic node and liver biopsy. The ovaries then were moved toward the midline and attached to the posterior aspect of the uterus. Only the spleen was enlarged. Pathologic examination showed multiple areas of Hodgkin’s disease in the spleen with negative para-aortic nodes and negative liver biopsy. The patient had an uneventful postoperative recovery and was discharged from the hospital on the eighth postoperative day. Ten days later, radiation therapy

REFERENCES

1. Brookes, V.: Proc. R. Sot. Med. 61: 216, 1968. 2. Dorman, J. E., Floyd, C. E., and Cohn, I.: Am. J. Surg. 113: 131, 1967. 3. Golden, T., and Stout, A. P.: Surg. Gynecol. Obstet. 73: 784, 1941. 4. Griggs, E. R.: Am. J. Med. 31: 591, 1961. 5. McElligot, M.: J, Ir. Med. Assoc. 63: 358, 1970. 6. McPeak, C. J.: Am. J. Surg. 114: 402, 1967. 7. Messe, A. A., Sasson, L., and Sherwin, B.: J. A. M. A. 174: 1706, 1960. 8. Middleton, W. R. J.: Amt. Ann. Med. 16: 155, 1967. 9. Pagtalunan, R. J, G., Mayo, C. W., and Dockerty, M. B.: Mayo Clin. Proc. 55: 45, 1964. 10. Patterson, J. F., Callow, A. D., and Ettinger, A.: Ann. Intern. Med. 48: 123, 1958. 11. Stanley, W., and Groshong, L. E.: Ann. Surg. 35: 809, 1969. 12. Strauch, G. 0.: Surgery 55: 240, 1964. 13. Wald, M.: Aust. N. 2. J. Surg. 33: 147, 1963.

reported and the information

Reprint Obstetrics

Center, ‘Ortho

because of the severity of the illness availability of sufficient bacteriologic to suggest the pathogenesis.

requests: Dr. Robert F. Porges, Department of and Gynecology, New York University Medical 550 1st Ave., New York, New York lCiO16. Pharm.

Corp.,

Raritan,

New

Jersey.

Volume Number

117

Communications

was started to the para-aortic nodes and hilum of the spleen. Five weeks following splenectomy, the patient had the sudden onset of diarrhea, nausea, vomiting, and persistent abdominal pain. At the time of hospitalization, diarrhea was voluminous, and the slightest change in position caused the passage of loose, mutinous stools. Temperature was 104” F. rectally, blood pressure 70/40, pulse 180, respirations 60. Examination of the lungs and heart was not remarkable. Examination of the abdomen revealed slight symmetric distention, generalized tenderness, guarding, and increased bowel sounds. The pelvic and rectal examinations were normal. The white blood cell count was 7,400 per cubic milliliter with 75 per cent segmented and 9 per cent band forms. The hematocrit was 40 per cent. Abdominal x-ray showed loss of the psoas shadow bilaterally and a normally positioned Lippes Loop. Treatment consisted of rapid hydration, antibiotics, and nasogastric suction. Twelve hours following admission, the temperature was 103” F., blood pressure 100/50, pulse 140, respirations 40. The abdomen was slightly more distended with increased tenderness in the right upper quadrant. Exploratory laparotomy was carried out 36 hours after admission, with a preoperative diagnosis of gangrenous cholecystitis and possible subhepatic abscess. The peritoneal cavity contained approximately 800 C.C. of purulent material with no areas of loculation or adhesions. The viscera appeared to be normal except for a mild serositis of the small bowel. The fimbriated ends of the Fallopian tubes were engorged and edematous and exuded purulent material. The abdomen was lavaged with saline and closed without drainage. A Gram stain of the peritoneal fluid revealed many leukocytes and many gram-positive cocci in small clumps. Cultures from the blood. abdominal cavitv. ,I Fallopian tubes, and cervix subsequently revealed Group A hemolytic streptococcus, type 43. The Lippes Loop was removed several hours

follow.irlg operation.

High-output

renal failure de-

veloped postoperatively and responded within 4 days to fluid and electrolyte replacement. A pleural effusion was noted on the right side and the patient bad a persistent low-grade temperature. On

the ninth postoperative day, the subphrenic was explored and no abscess was found.

area

Following treatment with penicillin, ampicillin, and oxacillin she was discharged 4 weeks after admission without fever and much improved.

Primary streptococcal peritonitis is a disease of the younger age group, affecting male and female

in brief

289

even in these patients, examination

of

2

subjects

with

equal

frequency.

In

this

variety of peritonitis, the triad of recent respiratory tract infection, abdominal pain, and sepsis is frequently seen. It is not uncommon for the initial fever to subside before abdominal discomfort starts, thereby obscuring the relationship.

However, the

throat

still

shows

signs

of pharyngitis.

Peritonitis of streptococcal origin is usually diffuse and frequently associated with ileus, nausea, vomiting, and diarrhea. The white blood cell count ranges between 14,000 and 22,000 per cubic milliliter. The diagnosis is usually confirmed by abdominal paracenteses. Blood cultures are positive in 40 per cent of patients. Diffuse reddening of the peritoneum with only a few weblike strands of fibrin between loops of the bowel is usually seen at operation. The abdominal fluid is odorless and turbid in appearance. Before

the

advent

of antibiotics,

the

mortality

rate

was as high as 80 per cent. Growing experience in the postoperative course of patients undergoing splenectomy for Hodgkin’s disease is now developing. In this group of patients, approximately 1 in 20 will develop bacteremia following splenectomy, with gram-positive bacteremia developing twice as commonly as the gram-negative variety or a mixed infection. The mortality rate in this group of patients with postsplenectomy bacteremia is generally 30 per cent. The intrauterine contraceptive device is very likely to have been the source of the infection in this patient. Streptococcus Group A, type 43, was cultured from the cervix, peritoneal cavity, Fallopian tube, and blood. Low-grade infections of the endometrium are believed to occur frequently within a few weeks after the insertion of intrauterine contraceptive devices. The recent literature contains at least 3 case reports’ of women with intrauterine contraceptive devices who had severe intra-abdominal infections necessitating laparotomy for drainage. Burnhill” has described a large number of women attending a contraceptive clinic who developed pelvic infections over a period of weeks or months, marked by foul-smelling vaginal discharge, intermenstrual bleeding, uterine tenderness, and pelvic pain. These symptoms were controlled by antibiotics, when recognized in time. Three deaths occurred in women with clinical courses

not

too

sented above. Considering pelvic

infections

dissimilar

the potential in

normal

from

the

patient

pre-

for mild and severe women

one

should

exercise caution in recommending this form of contraception in a patient with lymphoid disease, recent radiotherapy, and a recent splenectomy.

290

Communications

Septrmbel

in brief

.~m. J. Ohstrt.

REFERENCES

1.

Wilson,

E.,

2.

Burnhill, American Physicians,

and Dilts, P.: AM. J. OBSTET. 11’2: 237, 1972. M.: Presented at a Meeting of the Association of Planned Parenthood Detroit, Michigan, April, 1972.

GYNECOL.

Excision

of an ectopic

through

the

HOWARD F.A.C.O.G. DANIEL F.A.C.O.G.

laparoscope I.

H.

Department The Norwalk

pregnancy

SHAPIRO, ADLER,

M.D., M.D.,

of Obstetrics and Gynecology, Hospital, Norwalk, Connecticut

co PY is rapidly the most important operative able to the gynecologist. Its

LAPAROS

becoming procedures unquestioned

one of availdiag-

nostic accuracy and therapeutic uses have been stressed.19 2 The application of laparoscopy to the early diagnosis of ectopic gestation has been invaluable. Presented is a case report and discussion in which both diagnosis and treatment of an unruptured tubal pregnancy were performed laparoscopy. To our knowledge this is the patient treated in this manner.

via first

D. H., a 32-year-old, para 2-O-l-2 woman, was first seen in the Norwalk Hospital Emergency Room on November 9, 1972, complaining of rightsided lower abdominal pain of 3 hours’ duration accompanied by vaginal spotting. The last normal menses were at the end of September, and she had vaginal staining for 10 days at the end of October. Her temperature was 98.4” F., pulse 96 per respirations 20 per minute, and blood minute, pressure 120/70. There was tenderness to palpation in the right lower quadrant and minimal rebound tenderness; bowel sounds were normal. The cervix was clean, closed, not discolored, and slightly tender to motion. The uterus was anteflexed and of normal size and consistency. There was tenderness but no palpable mass in the right adnexa. The hemoglobin was 11.3 Gm., hematocrit 35 per cent, and white blood cell count 6,700 per cubic millimeter, with a normal differential. The urinalysis was normal and the pregnancy test was negative. Culdocentesis was negative. Repeat

131

Reprint Kings

requests: Highway

Dr. Howard I. North, Westport,

Shapiro, The Connecticut

Willows, 06880.

15, 1077

Gynrcrd

hematocrit, hemoglobin and complete blood count 4 hours later were essentially the same. Because of the possibility of an ectopic gesta-, tion, dilatation, curettage, and laparoscopy were performed. Curettings were minimal. Laparoscopy with the two-incision technique, in which the viewing laparoscope and the Palmer* biopsy tong are used through separate incision, was then performed. A 2 cm. unruptured pregnancy was present in the isthmus of the right tube. Blood was noted to be leaking from the tube, and approximately 25 C.C. of unclotted blood was noted in the cul de sac. Thorough coagulation of the tube medial and distal to the ectopic pregnancy was then performed with the Palmer biopsy tong. In addition, the blood vessels in the mesosalpinx below the tubal pregnancy were also coagulated. This prevented bleeding from branches of the ovarian and uterine arteries as well as their anastomosing vessels in the mesosalpinx. The portion of tube containing the pregnancy was then grasped with the biopsy forceps, and, by combined cutting and coagulation, the gestation was removed in 3 separate segments. Hemostasis was excellent, and the patient tolerated the procedure very well, leaving the hospital on the second postoperative day. Hemoglobin on discharge was 11.6 Gm. The pathology report confirmed the diagnosis of an ectopic gestation. Examination 2 weeks later was unremarkable. Ruptured ectopic pregnancy is responsible for 2 to 3 per cent of all obstetrically caused maternal deaths in the United States each year. Because of this, expectant therapy in the management of ectopic pregnancy is to be deplored. Laparoscopy has given physicians the opportunity to diagnose and treat ectopic pregnancy prior to rupture. In 35 cases of suspected ectopic pregnancy, Esposito’ diagnosed 12 unruptured tubal gestations with the use of laparoscopy. Those patients in whom laparoscopy was normal were spared unnecessary laparotomy or needless and costly observation in the hospital. All 12 ectopic pregnancies in his series were treated by laparotomy. The excision of an early isthmic pregnancy via laparoscopy proved to be an easy procedure in this particular instance. Hemostasis was achieved by extensive coagulation of the tubal branches of both uterine and ovarian artery and vein and their anastomosing vessels in the mesosalpinx. We would be hesitant to perform a laparoscopic excision on a gestation involving the isthmus of the tube immediately adjacent to the uterus. However, in early unruptured preg*Eder Chicago,

Instrument Illinois.

Co..

Inc.,

5115

N.

Ravenauwood

Ave..