DOI: 10.12890/2025_005890
Invasive pneumococcal disease presenting with abdominal pain, vomiting and diarrhoea in a patient with multiple myeloma
Authors
hdegoncalves@gmail.com
Keywords
Invasive pneumococcal disease, Streptococcus pneumoniae, pneumococcal peritonitis, pneumococcal bacteraemia, intra-abdominal infectionAbstract
Background: Streptococcus pneumoniae is a leading cause of community-acquired pneumonia and meningitis, but intra-abdominal manifestations are rare, particularly in adults without underlying peritoneal disease. Primary pneumococcal peritonitis is classically associated with cirrhosis, nephrotic syndrome, or peritoneal dialysis, and has seldom been reported in patients with haematological malignancies. Multiple myeloma significantly increases the risk of invasive pneumococcal disease due to impaired humoral immunity and hypogammaglobulinemia.
Case report: We report a 40-year-old woman with smouldering IgG lambda multiple myeloma presenting with abdominal pain, diarrhoea, vomiting, and hypotension. Laboratory tests revealed macrocytic anaemia, leukopenia with absolute neutropenia, acute kidney injury, elevated inflammatory markers, and compensated metabolic acidosis. A computed tomography (CT) scan of the abdomen and pelvis showed partially loculated ascites, peritoneal fat stranding, and thickening of duodenum, descending, and sigmoid colon walls. Blood cultures were positive for Streptococcus pneumoniae, confirming atypical invasive pneumococcal disease manifesting as spontaneous primary peritonitis with secondary enterocolitis. Despite broad-spectrum antibiotics, the patient developed persistent sepsis complicated by multiple intra-abdominal abscesses. Echocardiography and a spine CT scan excluded endocarditis or vertebral involvement. Source control was achieved through three ultrasound-guided percutaneous drainage procedures, resulting in gradual clinical and radiological resolution. She was discharged on day 42 with complete recovery and scheduled pneumococcal vaccination.
Conclusion: This case highlights a rare and severe gastrointestinal manifestation of invasive pneumococcal disease in a high-risk host. Spontaneous pneumococcal peritonitis complicated by multiple intra-abdominal abscesses is exceptionally uncommon in multiple myeloma. Early recognition, multidisciplinary management, and minimally invasive source control were crucial to a favourable outcome. Preventive strategies, particularly pneumococcal vaccination, remain essential to reduce morbidity in immunocompromised patients.
References
- Sousa A, Pérez-Rodríguez MT, Nodar A, Martínez-Lamas L, Vasallo FJ, Álvarez-Fernández M, et al. Clinical and microbiological characteristics of unusual manifestations of invasive pneumococcal disease. Enferm Infecc Microbiol Clin (Engl Ed) 2018;36:284-289. English, Spanish. doi: 10.1016/j.eimc.2017.05.003
- Gasparotto AM, Gianecini A, Kasparian A, Kremer L, Rocchi M, Quinteros Greco C, et al. Intra-abdominal infections in adults caused by Streptococcus pneumoniae: report of 18 cases. Rev Fac Cien Med Univ Nac Cordoba 2022;79:280-284. Spanish. doi: 10.31053/1853.0605.v79.n3.36024
- Capdevila O, Pallares R, Grau I, Tubau F, Liñares J, Ariza J, et al. Pneumococcal peritonitis in adult patients: report of 64 cases with special reference to emergence of antibiotic resistance. Arch Intern Med 2001;161:1742-1748. doi: 10.1001/archinte.161.14.1742
- Ortqvist A, Hedlund J, Kalin M. Streptococcus pneumoniae: epidemiology, risk factors, and clinical features. Semin Respir Crit Care Med 2005;26:563-574. doi: 10.1055/s-2005-925523
- Mazuski JE, Solomkin JS. Intra-abdominal infections. Surg Clin North Am 2009;89:421-437, ix. doi: 10.1016/j.suc.2008.12.001
- Taylor SN, Sanders CV. Unusual manifestations of invasive pneumococcal infection. Am J Med 1999;107:12S-27S. doi: 10.1016/s0002-9343(99)00103-5
- Fernandes S, Freire-Gomes A, Girão J, Miranda C, Coutinho J. Primary pneumococcal peritonitis in a healthy woman: case report and a literature review of the last 10 years. Revista Portuguesa de Cirurgia 2020;49:81-86. doi: 10.34635/rpc.766
- Shigayeva A, Rudnick W, Green K, Chen DK, Demczuk W, Gold WL, et al. Invasive Pneumococcal Disease Among Immunocompromised Persons: Implications for Vaccination Programs. Clin Infect Dis 2016;62:139-147. doi: 10.1093/cid/civ803
- Reisinger EC, Fritzsche C, Krause R, Krejs GJ. Diarrhea caused by primarily non-gastrointestinal infections. Nat Clin Pract Gastroenterol Hepatol 2005;2:216-222. doi: 10.1038/ncpgasthep0167
- Cleveland KO, Gelfand MS, Goswami R. Diarrhea as a symptom in bacteremic pneumococcal pneumonia. Infect Dis Clin Pract 2007;15:35-37. doi: 10.1097/01.idc.0000239715.39960.7f
- Ronnachit A, Ellenberger KA, Gray TJ, Liu EY, Gilbey TL, Cheong EY, et al. Streptococcus pneumoniae causing intra-abdominal and pelvic infection: a case series. Cureus 2017;9:e1967. doi: 10.7759/cureus.1967.
- Inui T, Haridas M, Claridge JA, Malangoni MA. Mortality for intra-abdominal infection is associated with intrinsic risk factors rather than the source of infection. Surgery 2009;146:654-662. doi: 10.1016/j.surg.2009.06.051
