Spontaneous Bacterial Peritonitis with Sepsis Caused by Enterococcus hirae
A 61-yr-old male with decompensated cirrhosis and type 2 diabetes mellitus was admitted to emergency room because of abdominal pain, fever, chills and generalized weakness on November 20th, 2011. He had been diagnosed as alcoholic liver cirrhosis 5 yr ago and followed up with regular examinations. He had received norfloxacin (400 mg per day) for secondary prevention of SBP after hospitalization by Klebsiella pneumoniae-associated SBP 4 months ago. He looked vitally stable at first with blood pressure of 110/80 mmHg, heart rate of 92 beats/min, and body temperature of 39.3℃. However, blood pressure rapidly declined to 80/50 mmHg in 3 hr of admission, which prompted a sufficient fluid replacement and even inotropics. On physical examination, his abdomen was protuberant, but there was no tenderness and rebound tenderness. The rest of the examination was unremarkable.\nInitial laboratory findings were as follows: white blood cell (WBC) 7,590/µL with left deviation (neutrophil 90%), hemoglobin 13.4 g/dL, platelet 87,000/µL, C-reactive protein (CRP) 50.2 mg/L, total bilirubin 3.2 mg/dL, albumin 2.7 g/dL, INR 1.63, aspartate transaminase 16 IU/L, alanine transaminase 9 IU/L, serum creatinine 1.7 mg/dL. Based on the finding of physical and laboratory examination, his stage of cirrhosis was classified as Child-Pugh class C. Analysis of ascitic fluid revealed a WBC count of 6,560/µL with 90% neutrophil and a red blood cell count of 1,440/µL, the protein levels of 1.6 g/dL, albumin levels of 0.7 g/dL. Urinalysis, chest X-ray and electrocardiography were normal.\nIntravenous cefotaxime (2 g every 12 hr) was empirically started on the presumptive diagnosis of SBP, pending the results of culture. Two days even after antibiotic coverage, the patient was still febrile and laboratory findings did not improve in terms of serum CRP (138 mg/dL) and WBC count in the ascitic fluid. Antibiotics were changed to vancomycin (1 g every 12 hr) combined with ciprofloxacin (200 mg every 12 hr) when gram positive cocci were isolated in both ascitic fluid and blood cultures. Subsequently, fever subsided and laboratory findings were gradually improved.\nAscitic fluid and blood cultures obtained on admission yielded an Enterococcus spp., which was identified at the species level as E. hirae using automated MicroScan WalkAway system (Microscan® WalkAway®-96 Plus, Siemens Healthcare Diagnostics Inc., CA, USA) and sucrose fermentation test. The strain was sensitive to ampicillin, vancomycin, teicoplanin, erythromycin, tetracycline, and high-level streptomycin and gentamicin. According to antibiotic sensitivity test, it was replaced by intravenous ampicillin (2 g every 6 hr). The patient was clinically resolved and discharged without complications on December 7th, 2011.