The genus Yersinia comprises a group of Gram-negative rod-shaped bacteria that are broadly distributed in the environment. This genus encompasses 17 different species of which 3 organisms are virulent to humans. These include Yersinia pestis, Yersinia enterocolitica, and Yersinia pseudotuberculosis. Both Y. enterocolitica and Y. pseudotuberculosis are known to cause an enteric illness; however, Y. pseudotuberculosis is rare in humans compared to Y. enterocolitica, which is more commonly seen.[1][2][3]
Yersinia pseudotuberculosis infection is usually acquired through the consumption of contaminated foods and water. Yersinia pseudotuberculosis is present in the soil and can be seen in fresh farm-produced plants and root vegetables. It has numerous animal reservoirs and is abundant in wildlife, including birds, rodents, rabbits, deer, dogs, cats, and cattle.[2][4][5][4].
The incubation period varies from 5 to 10 days. A latent period of 2 to 20 days has been reported, with peak incidence rates at 4 days after ingestion.
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The enteropathogen, Yersinia pseudotuberculosis, requires a large inoculum to produce the disease. The primary virulence factor is a plasmid-encoded protein that causes increased invasiveness. Yersinia pseudotuberculosis survives intracellularly.
Yersinia pseudotuberculosis inhabits and grows in the gastrointestinal tract, initially in the Peyer's patches, and then spreading to the liver and the spleen through the mesenteric lymph nodes or directly.[2]
Yersinia pseudotuberculosis has a siderophore-mediated iron scavenging system that contributes to its virulence.[6] Patients with iron overload disorders like venous congestion, hemochromatosis, cirrhosis, and hemolytic anemias are, therefore, at a slightly higher risk for systemic infections.[7]
In general, the appendix will appear normal, but the nearby mesenteric lymph nodes and Peyer's patches may show epithelioid granulomatous lesions, coagulative necrosis, and lymphoid hyperplasia, and can resemble tuberculosis. The small bowel may develop microabscesses, cryptic hyperplasia, and shortening of villi. Granulomatous abscesses form in organs like the liver, spleen, lungs, kidneys, and the intestines when the organism spreads during sepsis.[8]
Y. pseudotuberculosis causes self-limiting acute gastroenteritis and mesenteric lymphadenitis that mimics acute appendicitis. The enteritis is usually seen in children as opposed to the mesenteric adenitis seen in the adults.[5] Symptoms include abdominal pain, fever, vomiting, and diarrhea. The abdominal pain is often located in the right lower quadrant and may mimic appendicitis.
Other problems associated with Yersinia pseudotuberculosis infection include terminal ileitis and intussusception, more commonly in children. In most cases, enterocolitis lasts one to three weeks. Erythema nodosum, arthralgias, reactive arthritis, ankylosing spondylitis, and lumbar facet joint disease can occur. A sporotrichoid pattern of disease has been associated with Yersinia pseudotuberculosis infection. Cutaneous manifestations include erythema of the face and neck, conjunctival hyperemia, strawberry tongue, punctate skin rash, and desquamation. Ophthalmic findings such as uveitis and conjunctivitis have also been reported.
Physical findings caused by Yersinia pseudotuberculosis infection may be grouped into three main categories: systemic, enteric, and rheumatologic.
Patients with immunosuppression and iron-overload states such as hemochromatosis, venous congestion, hemolytic anemia, and cirrhosis are at risk for sepsis.[9][10][11]
The laboratory diagnosis of Yersinia pseudotuberculosis requires confirming the presence of the organism to support the clinical diagnosis. The acquisition by culture-positive sources such as blood, cerebrospinal fluid, peritoneal fluid, synovial fluid, or other organ-based biopsy is confirmatory.[12][13]Microbiology
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In patients with mesenteric lymphadenitis, CT scans or ultrasound may reveal enlarged mesenteric lymph nodes and peritoneal findings including inflammation of the appendix and terminal ileitis.
In pneumonic or septic presentations, a chest x-ray may reveal infiltrates suggestive of acute pneumonia.
In the rare Kawasaki disease–like variant, Izumi fever, ECG abnormalities may suggest ischemia if aneurysms compromise coronary artery circulation. These abnormalities are more likely to develop in children.
Yersinia pseudotuberculosis infection is usually self-limited. More toxic presentations, including septic syndromes or severe dehydration, may require hospitalization. General supportive care is needed.[14][15]
Though antibiotics are not required for a mild illness, serious manifestations like sepsis occurring in a patient with immunosuppression or chronic liver disease warrant the usage of antibiotics.[2]
The fluoroquinolone group of drugs was found to be the most effective in the treatment of Y. pseudotuberculosis as per in-vitro and in-vivo murine studies. Antibiotics belonging to other classes were unable to inhibit the bacterial growth to a significant extent as compared to fluoroquinolones.[16][17][18] Nevertheless, antibiotics like ampicillin, ceftriaxone, doxycycline, and gentamycin have been successful in the treatment of Y. pseudotuberculosis and its complications following previously documented case reports.[19][20][21]
Exploratory laparotomy may be warranted in patients with complications such as severe GI bleeding, and intestinal obstruction. However, this intervention is not common.[22][23]
The majority of cases of Yersinia pseudotuberculosis are mild and self-limited. In immunocompromised patients and those with chronic liver disease, the disease can be fatal.[24][25] (Level III) These patients may develop a severe disease that can lead to sepsis and generalized involvement of the intestine.
The diarrhea, fever, and anorexia may last a few days or weeks and thus the patient should be kept NPO. IV hydration is recommended during this time period.
Consult gastroenterology, or surgery if invasive diagnostic or therapeutic interventions are warranted. For unusual presentations, rheumatologic, dermatologic, or ocular complications; additional consultation with an infectious disease specialist should be considered.
The patient should be educated on food hygiene and the fact that the organism is cold tolerant. There is no vaccine available.
Because the infection can mimic many other disorders, consultation with an infectious disease specialist, a gastroenterologist, and a surgeon should be sought.[27][14] (Level III) Healthcare workers at all levels should be educating the public on food hygiene and the proper cooking of food. Nurses are often the last to see the patients in the emergency room and at discharge and are in a prime position to educate the patient and the family about proper food practices. The nurse should also educate the patient on the signs and symptoms of the infection so that the patient seeks immediate care.
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