Yersinia Infection 02.10.2012

8/2/2019 Yersinia Infection 02.10.2012

1/18

MORNING REPORT

Liset Olarte MD, PGY2

February 10, 2012


2/18

HISTORY

HPI:

12y male with abdominal pain off and on "his entire life on his rightside.

Worsening abdominal pain, backache 2-3 weeks ago.

Low grade fever , poor appetite for 5 days.

Diagnosed with asthma and possible pneumonia. Steroids,Azithromycin, and Albuterol.

3 and 2 days PTA, ER visit: fluids, morphine.

Has loose stool/constipation, nausea, emesis x1, has lost weight.No blood in stool


3/18

HISTORY

PMH

:- Chronic abdominal pain

- Encephalitis/meningitis due to West Nile at 4 yo

MEDS: none

ALLERGIES: Bactrim

IMMs: UTD, no flu shot

FAMILYHX: Mom: rhabdomyolysis, migraines, chronic abdominal pain,

glaucoma. Sibling chronic abdominal pain. Father's history unknown.

SOCIAL HX: Lives in WY with mom, 2 younger siblings and mom's boyfriend.Family lives on a farm.


4/18

PHYSICAL EXAM

T 37.8, P 98, RR 28, BP 99/61

Weight 34.5 (7%ile)

GENERAL: Well appearing, mild distress .

EYES: EOMI, PERRL, conjunctivae clear, sclerae nonicteric,

HENT: NC/AT, MMM, NP clear, OP w/o exudates.

LYMPH: Neck supple, small ~1cm lymph node palpated in the L anterior cervical

chain.

LUNGS: CTAB, no increased WOB, good aeration, no adventitious sounds.

CV: RRR, no M/R/G, nl perfusion and pulses.

ABD: Soft, tender throughout but significantly worse on RLQ, hypoactive BS , no

HSM, no mass.GU: Small


5/18

DIFFERENTIALDIAGNOSIS

GI: Ulcerative Colitis, Crohn Disease, Appendicitis, Constipation, Mesenteric adenitis,Bowel obstruction, Abdominal migraine, Cholecystitis, Functional abdominal pain,hepatitsi, pancreatitis, meckels diverticulum, gastritis, perforated ulcer, foreign bodyingestion

ID: Amebiasis, Intraabdominal abscess, Gastroenteritis, Cholangitis, CampylobacterInfections, Clostridium Difficile Colitis, yersinia, shigellosis, salmonellosis

CV: Myocarditis, pericarditis.

Resp: Pneumonia

Endo/metab: diabetic ketoacidosis, acute porphyria

GU/renal: Urinary tract infection, Urolithiasis,HUS

Heme/onc: Sickle cell vasooclusive crisis, lymphoma

Tox: Lead poisoning


6/18

OSH LABS

Na 137, K 4, Cl 100, HCO3 27, BUN 11, Cr 0.7, Glu 107, Ca 8.9, Mag 1.9

CRP 18.8, ESR 34

Lipase 80

AST 17, ALT 30, Tbili 0.3, Prot 6.3, Alk phos 270, Alb 3.8

WBC 12.6 (L 17, M 12, N 77), Hct 38, Plat 192.

Overread of OSH CT abd:

1. Terminal ileum and cecal wall thickeningsuggesting IBD, less likely

infectious enterocolitis.

2. Right lower quadrant mesenteric adenopathy.

3. No free air. No intra-abdominal abscess. Remainder of the bowelappears normal.

CXR: Normal.


7/18

PCMC

CRP 18, ESR 50

HFP, uric acid, LDH normal

Blood and stool culture sent

DOH #2 Endoscopy showed:

Normal esophagus and duodenum,

Gastritis with patchy erythema.

Purulent exudate at ileum and thickened, beefy IC valve.

Patchy ulcerations in proximal colon through mid-transverse colon.

No anal lesions.

He was started on IV Solumedrol Prednisone.

PPD placed in case he needed Remicade. Morphine oxycodone and levsin for pain.

DOH #3 Blood culture : Gram negative bacilli. Started on IV Zosyn and POFlagyl.


8/18

PCMC

DOH #5

Blood culture: Yersinia enterocolitica. S: ampicillin/sulbactam, cefepime, cefoxitin, ceftazidime, ceftriaxone, ciprofloxacin,

gentamicin, imipenem, levofloxacin, meropenem, tobramycin

I: ampicillin

R: cefazolin, trimeth/sulfa

Discontinued prednisone

Antibiotics switched to Ceftriaxone and Gentamicin

Transitioned to PO Ciprofloxacin

Pathology report: Acute enterocolitis, with minimal chronic change noted .

Day after discharge Stool culture positive for Yersinia enterocolitica.


9/18

YERSINIA INFECTION


10/18

WHY IS YERSINIA INFECTION

IMPORTANT?

The incidence ofYersinia infections is highest in youngchildren.

77.6% of infections occurred in children aged < 12 months.

Young children are susceptible due to their immatureimmune systems.

17,000 cases occur annually in the United States

530 cases will be severe enough to require hospitalization 29 deaths are possible each year.


11/18

YERSINIA ENTEROCOLITICA

Gram-negative bacillus

Healthy pigs are frequently colonized with

strains that cause human illness Can be found in dogs, cats, pigs, cows, sheep,

goats, rodents, foxes, and birds.

More common duringwinter months(psychrophilic)

More common in developed countries.


12/18

TRANSMISSION

Contaminated food, raw or undercooked

pork products.

Contaminated unpasteurized milk or

untreated water

Contact with infected animals.

Transfusion of stored blood from

asymptomatic donors.

Cross-contamination: hands of theperson handling the raw food bottle,

pacifier, toys of the infant.


13/18

CLINICAL PRESENTATION

Incubation period is typically 46 days

Most frequently associated:

acute diarrhea (1-3 weeks)

terminal ileitis

mesenteric lymphadenitis

Pseudoappendicitis

Infected individuals may shed Y enterocolitica instools for 90 days after the symptom resolution.

The most prominent clinical manifestations in youngchildren are fever and diarrhea (bloody)


14/18

COMPLICATIONS

GASTROINTESTINAL EXTRAINTESTINAL

Diffuse ulcerating ileitis and

colitis

Intestinal perforation

Peritonitis

Intussusception

Paralytic ileus

Toxic megacolon

Necrotic small bowel

Cholangitis

Mesenteric vein thrombosis

Bacteremia

Hepatic, splenic, renal, lung

abscess

Pharyngeal abscess

Endocarditis

Meningitis

Osteomyelitis

Septic arthritis

Suppurative lymphadenitis


15/18

BACTEREMIA

Most often in children < 12months

Older children with predisposing conditions :immunosuppresive state or iron overload storage(ferrophilic )(thalassemias, sickle cell disease,hemochromatoses)

Death is uncommon, but Y enterocoliticabacteremia carries a case fatality rate of 35%.


16/18

POST-INFECTIOUS SEQUELAE

Reactive arthritis, large

weight-bearing joints

(knees, ankles, wrists).1 month after the

initial episode of

diarrhea

resolves in 1 to 6

months.HLA-B27 is typically

present

Proliferative

glomerulonephritis

Erythema nodosum,resolves within a month.


17/18

DIAGNOSIS

CIN agar, selective medium withincreased yield for Y

enterocolitica

Recovery from sterile samples(blood, CSF, lymph node tissue)is usually faster than stoolsamples.

Serologic assays are of limitedclinical utility due to cross-

reactivity (Brucella, Salmonella,Rickettsia, E.coli)


18/18

TREATMENT

Uncomplicated cases of diarrhea resolve on their own

Antibiotic treatment may reduce the duration of fecal shedding.

In severe or complicated infections: aminoglycosides, doxycycline, TMP-

SMX, or fluoroquinolones

Bacteremia treat for 3 weeks.

Ceftriaxone + gentamicin

Ciprofloxacin

Antimicrobial therapy has no effect on post-infectious sequelae

Rapid microbiologic clearance of the organism

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Yersinia Infection 02.10.2012