Spontaneous bacterial peritonitis with a very high leukocyte count in ascitic fluid caused by Haemophilus influenzae
A 64-year-old Jewish male of Indian origin was hospitalized in our department, with a 5-day history of fever (39°C), cough, and fatigue. He denied abdominal pain, vomiting, diarrhea, or other symptoms.\nHis medical history was significant for alcoholic cirrhosis with portal hypertension, splenomegaly, hypersplenism, and ascites. Furthermore, he had diabetes mellitus type 2 (hemoglobin A1c of 7%) and hypertension for years.\nHis medications included propranolol, lactulose, Aldospirone, omeprazole, and metformin.\nOn physical examination the patient was alert without encephalopathy or jaundice. The following characteristics of chronic liver disease were present: spider angiomas on his chest, hepatomegaly, splenomegaly, ascites, caput medusa, and pedal edema. His abdomen was swollen with tenderness in the right upper quadrant.\nLaboratory tests showed a total bilirubin level of 1.76 mg/dL (normal range, 0.21–1 mg/dL); alanine aminotransferase level of 20 U/L (normal values, <40 U/L); aspartate aminotransferase level of 24 U/L (normal values, <40 U/L); alkaline phosphatase level of 147 U/L (normal range, 30–150 U/L); γ-glutamyl transpeptidase level of 73 U/L (normal range, 5–60 U/L); albumin level of 1.3 g/dL; prothrombin time of 15 seconds (international normalized ratio, 1.4); creatinine 2.7 mg/dL. His Model for End-Stage Liver Disease score on admission was 22. Complete blood count showed leukocytosis, 14,000 cells/μL, with 85% neutrophils, hemoglobin 7.1 g/dL, and platelets 100,000 cells/μL.\nChest X-ray showed mild right pleural effusion with no pulmonary infiltrates, and his abdominal ultrasonograph showed moderate ascites and hepatosplenomegaly. Blood, urine, and pleural fluid cultures were negative.\nAbdominal paracentesis was done and revealed 134,800 leukocytes/mm3 (100% neutrophils), a serum-ascites albumin gradient of 1.4; levels of lactate dehydrogenase, amylase, and triglycerides were not elevated, and the level of glucose was within normal limits. The unusually high peritoneal fluid leukocyte count raised the suspicion of secondary peritonitis.\nThe patient underwent computed tomography of the abdomen with oral contrast, and no evidence of perforation or abdominal abscess was found.\nA peritoneal fluid culture was positive for H. influenzae, and the patient was treated with ceftriaxone. Abdominal paracentesis was repeated 48 hours after beginning antibiotic treatment and showed a significant decrease of leukocyte count to 3,000/mm3. After hospitalization for 2 weeks the patient improved significantly; his fever resolved, and the patient felt better and was discharged. Three days later, the patient readmitted with septic shock due to Escherichia coli and methicillin-resistant Staphylococcus aureus. Unfortunately, despite antibiotic therapy, the patient died.