GRAM NEGATIVE PRIMARY PERITONITIS IN NEPHROTIC SYNDROME

Dear Editor,

We are reporting a case of nephrotic syndrome complicated by acute gram negative peritonitis. A high index of suspicion, early diagnosis and treatment is essential for this potentially fatal complication.

A 9 1/2-year-old boy, known case of nephrotic syndrome in remission on alternate day steroids presented with fever and pain in abdomen. He had stopped steroids 2 weeks prior to this admission on his own. He had abdominal tenderness, rebound tenderness, guarding and rigidity. Peritoneal tap was suggestive of bacterial peritonitis with polymorph 600/cumm. Gram stain revealed gram negative organisms. However, culture was sterile. In view of features of peritonitis an exploratory laparotomy was done to rule out a perforation, which was found to be absent. He was managed with parenteral cefotaxime and gentamicin. Post op recovery was uneventful. After two weeks he was restarted on steroids and is presently in remission.

Primary peritonitis refers to an acute purulent inflammation of peritoneal cavity without identifiable intra-abdominal source [2]. Nephrotic syndrome in children predisposes to this condition. Most are in relapse or on steroids [1]. Predominant organism is Streptococcus pnuemoniae (38%), culture negative in 27% while only 3% were due to gram negative organism [3]. Ascitic fluid should be obtained in sufficient quantity, centrifuged and cultured to improve growth on culture. Prophylaxis with pneumococcal vaccine reduces incidence of infection in nephrotic syndrome [4]. Treatment is essentially conservative. Surgery is indicated either in case of suspected perforation or if no improvement is seen after 48 hours of appropriate antibiotics. Surgery was considered in our case due to presence of gram negative organism in asitic fluid which is very rare in such cases.