AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Yersinia enterocolitica is a well-described enteric pathogen with distinctive clinical manifestations, a range of outcomes, and a predilection for children. In 1939, Schleifstein and Coleman first described Y enterocolitica. Approximately 75% of patients with Y enterocolitica infection are children aged 5-15 years. The spectrum of disease ranges from asymptomatic to life-threatening sepsis, especially in infants.

Pathophysiology

This organism belongs to the family Enterobacteriaceae, genus Yersinia, which includes 11 species. Three of these species are pathogenic in man: Yersinia pestis (bubonic plague), Yersinia pseudotuberculosis (mesenteric adenitis), and Y enterocolitica. Y enterocolitica is an oxidase-negative, non–lactose-fermenting, gram-negative coccobacillus that is motile at 22°C but is not motile at 37°C. Biotyping and serotyping can be performed. Of the 34 serotypes of O antigen, types 0:3 (sporadic cases in the United States);¹ 0:5,27; 0:8 (food-borne outbreaks in the United States); and 0:9 are the most common and represent the most virulent worldwide causes of human yersiniosis. Virulence can be chromosomal or via plasmid encoding.

Y enterocolitica grows most efficiently in environments with a pH of 5.0-9.0, hence the increased incidence of the disease in patients who take antacids and histamine 2 blockers. The organism requires iron to survive, and Yersinia sepsis has been reported in clinical states of iron overload, such as hemochromatosis, and in children following accidental iron overdose. Y enterocolitica grows on basic enteric media, producing subtle pinpoint colonies after 24 hours of incubation. Optimally, if Y enterocolitica is suspected, cefsulodin-irgasan-novobiocin agar should be used.

After ingestion of the organism, the terminal ileum is the site of mucosal adherence and penetration, followed by reproduction of the organism in Peyer patches. Nonspecific ileocolitis is often noted, with an inflammatory infiltrate in the lamina propria. The bacteria may then spread to the mesenteric lymph nodes; this spread may lead to bacteremia or to the development of abscesses and pain in the right lower quadrant that mimic the pain of appendicitis.² Although Y enterocolitica does produce a heat-stable enterotoxin similar to that of Escherichia coli, the enterotoxin does not contribute to the pathogenicity of the organism. Plasmid-encoded proteins of the outer membrane represent a major determinant in the pathogenicity of Y enterocolitica by contributing to adherence and invasion of the organism; antibodies directed against these proteins are present in patients convalescing from disease.

Frequency

United States

Y enterocolitica infection is more common in cooler climates, and its prevalence peaks from November to January.³ Y enterocolitica has been isolated in 1.4-2.8% of stools of children with diarrhea. Disease occurs in 1 person per 100,000 population per year in the United States.

International

Most frequently recognized in Northern Europe.

Mortality/Morbidity

The incubation period is 1-14 days, and the duration of stool excretion is 14-97 days. Symptoms typically persist for 5-14 days.

Sex

The male-to-female ratio is 1.7:1.

Age

Most infections occur in children younger than 7 years, with most younger than 1 year.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Y enterocolitica infection may be asymptomatic; however, several syndromes are associated with Y enterocolitica infection in children.

• Enterocolitis
• • Enterocolitis, the most common presentation, occurs primarily in young children, with a mean age of 24 months.
  • The incubation period is 4-6 days, typically with a range of 1-14 days.
  • Prodromal symptoms of listlessness, anorexia, and headache may be present. Such symptoms are followed by watery, mucoid diarrhea (78-96%); fever (43-47%); colicky abdominal pain (22-84%); bloody stools (<10%); and WBCs in the stool (25%).
  • Duration of diarrhea is generally between 1 day and 3 weeks.
  • Concomitant bacteremia may occur in 20-30% of infants younger than 3 months.
  • Most cases are self-limited.
  • Complications include appendicitis, diffuse ulceration and inflammation of the small intestine and colon, peritonitis, meningitis, intussusception,⁴ and cholangitis.
• Pseudoappendicitis syndrome
• • Characteristics include fever, abdominal pain, tenderness in the right lower quadrant, and leukocytosis.
  • Pseudoappendicitis syndrome is caused by infection with Y pseudotuberculosis.
  • Infection causes mesenteric lymphadenitis with terminal ileitis.
  • Pseudoappendicitis syndrome is more common in older children and young adults.
• Extraintestinal infections
• • These infections are rare, are most common in females, and can occur in the absence of bacteremia.
  • Examples include the following:
  • • Cellulitis
    • Conjunctivitis
    • Meningitis
    • Osteomyelitis
    • Pharyngitis
    • Pneumonia⁵
    • Pyomyositis
    • Urinary tract infection
• Bacteremia: Bacteremia is seen most frequently in patients with chronic disease or patients in an iron-overloaded state (eg, acute iron ingestion, sickle cell disease, thalassemia) because iron is a major growth factor for these bacteria.
• Postinfectious, nonsuppurative sequelae: Such sequelae, which are uncommon, include reactive polyarthritis, erythema nodosum, and proliferative glomerulonephritis. These sequelae are associated with human leukocyte antigen HLA-B27 and older age.

Physical

• Clinically, suspect Y enterocolitica infection in children with watery, bloody, mucoid diarrhea; a positive stain for WBCs; and exposure to uncooked meat products, particularly pork.
• Physical findings mimicking appendicitis may be noted.
• Less commonly, pharyngitis, cellulitis, meningitis, conjunctivitis, pneumonia, arthritis, and erythema nodosum are observed.

Causes

• Animal reservoirs
• • Swine (principle reservoir)
  • Cattle
  • Dogs
  • Rodents
  • Sheep
  • Cats
• Transmission
• • Transmission is primarily via ingestion of contaminated foods, water, and milk.
  • Fecal-oral transmission among humans has not been proven.
  • Transmission via blood products has occurred.
  • Infection can be transmitted from mother to newborn infant.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Stool culture
• • Stool culture is the best way to confirm this diagnosis.
  • Culture is usually positive within 2 weeks of onset of disease.
  • Instruct the laboratory to plate enteric specimens onto enteric media, with incubation at 25°C for 48 hours. If Y enterocolitica is suspected, cold enhancement techniques or cefsulodin-irgasan-novobiocin agar should be used.
• Agglutination
• • Agglutination titers rise one week after onset of illness and reach maximal levels at 2 weeks; elevated levels can be found for years after infection.
  • In the presence of suspected postinfectious disease, bacteriologic confirmation is generally not possible.
  • Agglutinin titers greater than 1:128 aid in the presumptive diagnosis of a previous infection with Y enterocolitica.
• False positive results: In the presence of thyroid disease, false positive results are seen.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• Care is primarily supportive.
• Antibiotics do not influence the course of uncomplicated enteritis.
• Always aggressively treat infants younger than 3 months, immunocompromised children, and patients with extraintestinal disease. This treatment is best accomplished in a hospital setting with intravenous antibiotics.

Diet

• Dehydration
• • If the child is dehydrated, institute appropriate oral rehydration.
  • Intravenous rehydration may be necessary if the child is in critical condition or unable to maintain oral hydration.
• Nutrition: Adequate nutrition is mandatory to prevent malnutrition and promote healing.

Activity

• Activity is permitted as tolerated.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Good nutrition and hydration are the mainstays of treatment. Antibiotics are indicated only as outlined. Tetracycline has traditionally been the drug of choice (DOC); however, increasing resistance is documented. In addition, these drugs should not be routinely used in children younger than 8 years.

First-line drugs include aminoglycosides and trimethoprim-sulfamethoxazole. Other effective drugs include third-generation cephalosporins, tetracyclines, chloramphenicol, and fluoroquinolones (not approved for use in children <18 y). Yersinia organisms are uniformly resistant to penicillin G and ampicillin, with or without clavulanate. Antimotility agents are contraindicated in the treatment of Y enterocolitica infection because of the increased risk of invasion.

Drug Category: Antibiotics

For appropriate Yersinia infections, the following antibiotics have been proven effective.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Deterrence/Prevention

• Eliminate reservoirs and minimize the contamination of food products.
• Always institute enteric precautions in the care of patients hospitalized with infection.
• Avoid unpasteurized milk and raw pork, particularly chitterlings,⁶ which are often consumed during the holiday season.
• No vaccine is available.

Complications

• Appendicitis
• Bacteremia
• Cholangitis
• Diffuse ulceration and inflammation of the small intestine and colon
• Intussusception
• Meningitis
• Osteomyelitis
• Peritonitis
• Reactive polyarthritis
• Hemolytic anemia

Prognosis

• Early recognition and prompt therapy, when indicated, optimize the outcome for the patient.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to diagnose or delay in diagnosis can lead to inappropriate use of ineffective antibiotics, anti-inflammatory agents, corticosteroids, immunosuppressants, antimotility agents, and surgery to treat children with yersiniosis, to the detriment of the patients.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Jan 17, 2008