Yersinia terminal ileitis: sonographic findings in eight patients

Yersiniosis: a forgotten mimicker and confounder of Crohn’s disease

Yersiniosis is a zoonosis caused by the Yersinia bacterium. The route of infection is most commonly oral and is caused by consumption of Yersinia-contaminated food. The clinical presentations of chronic yersiniosis are abdominal pain, diarrhea, relapsing arthritis, and skin lesions, that is, nodular erythema. The diagnosis is based on culture-dependent identification of Yersinia in stool, positive serologic test results, or molecular techniques. The treatment of choice is combination antibiotic therapy. Mild forms of the disease do not usually require treatment. Yersiniosis frequently mimics or confounds other chronic intestinal and extraintestinal inflammatory conditions, particularly Crohn’s disease. Therefore, diagnosis of yersiniosis may be a challenge for medical practitioners. Not including Yersinia infection in the differential diagnosis of abdominal symptoms can lead to an incorrect diagnosis and inappropriate treatment. This review summarises the current knowledge of Yersinia enterocolitica and pseudotuberculosis infection, with special focus on differential diagnosis between this infection and Crohn’s disease.

Differentiation of Yersinia enterocolitica enteritis from other bacterial enteritides by ultrasonography: A single-center case-control study

BACKGROUND

The diagnosis of Yersinia enterocolitica (Ye) enteritis is not easy because detection from stool culture is more difficult for Ye than for other bacterial enteritides. The establishment of characteristic ultrasonographic findings for Ye enteritis would help improve the detection rate of Ye enteritis along with performance of several cold cultures. This would facilitate appropriate selection of antibiotics based on antimicrobial susceptibility testing and contribute to a more accurate understanding of local public health. This study aimed to retrospectively compare ultrasonographic findings and clinical features between children with Ye enteritis and other bacterial enteritides.

METHODS

We identified patients treated for Ye enteritis (Ye group; n = 27) or other bacterial enteritides (Other enteritis group; n = 29) between 2014 and 2018. Ultrasonographic findings (including mean maximum diameter and mean major-minor axis ratio of ileocecal lymph nodes, wall thickness of the terminal ileum, and presence of a pericecal hyperechoic region), clinical symptoms, and laboratory findings at first visit were compared between groups.

RESULTS

No difference in mean maximum diameter of ileocecal lymph nodes was seen between groups. However, mean major-minor axis ratio of ileocecal lymph nodes was lower in the Ye group than in the Other enteritis group (p < 0.001). Presence of a pericecal hyperechoic region was more frequent in the Ye group than in the Other enteritis group (p < 0.001). The combined presence of a mean ileocecal lymph node major-minor axis ratio <1.51 and a pericecal hyperechoic region offered 100% sensitivity.

CONCLUSION

Characteristic ultrasonographic findings identified in this study may improve ultrasonographic differentiation of Y. enterocolitica enteritis from other bacterial enteritides.

Mesenteric Lymphadenitis and Terminal Ileitis is Associated With Yersinia Infection: A Meta-analysis

BACKGROUND

Yersinia infection affects terminal ileum and lymph nodes and could therefore mimic the symptoms of appendicitis. We aimed to systematically characterise the suspected or confirmed abdominal diseases and/or surgeries associated with Yersinia infection.

MATERIALS AND METHODS

This systematic review and meta-analysis was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A protocol (CRD42016053252) was uploaded to PROSPERO. The searches were conducted in PubMed and EMBASE on October 2, 2020. Original reports on patients with abdominal surgical diseases were included. The primary outcome was to characterise suspected or confirmed abdominal surgical diseases and/or surgeries associated with Yersinia infection, while the secondary outcomes were the positive rate of Yersinia species for each disease and surgery, and to investigate the rate of Yersinia spp. in different geographic regions. We calculated the weighted mean prevalence of positive tests for Yersinia spp. for the different diseases and surgeries according to the detection method and for subgroups based on geographic region.

RESULTS

From the search, 33 studies were included in the systematic review and 18 in the meta-analysis. Across geographic regions, the weighted mean prevalence for Yersinia spp. was 51% (95% CI 34%-69%) in mesenteric lymphadenitis, 65% (95% CI 45%-85%) in terminal ileitis, and 8% (95% CI 2%-15%) in normal appendices.

CONCLUSIONS

Around half of the patients with mesenteric lymphadenitis and terminal ileitis were serologically positive for infections with Yersinia spp. Yersinia infection may cause unnecessary surgery for suspected appendicitis due to symptoms from mesenteric lymphadenitis or terminal ileitis.

Yersinia pseudotuberculosis Infection Complicated with Bacteremia in a 10-Month-Old Boy

Yersinia pseudotuberculosis (Y. pseudotuberculosis) infection complicated with bacteremia rarely occurs. Y. pseudotuberculosis infection is also known to produce various symptoms similar to Kawasaki disease (KD) due to the production of Y. pseudotuberculosis-derived mitogen (YPM), an exotoxin with superantigen activity. Moreover, it causes terminal ileitis and is responsible for appendix swelling. Here, we report a case of Y. pseudotuberculosis infection in a 10-month-old boy who was brought to our hospital due to fever, watery stool, and poor vitality. Abdominal echocardiography revealed wall thickening of the entire colon and appendix swelling; therefore, he was admitted and treated with antibiotics for bacterial enteritis or appendicitis. After the antibiotic administration, facial skin rashes and hand and foot edema developed. However, he had 5/6 major symptoms of KD and was diagnosed with Y. pseudotuberculosis infection because of its presence in the blood and stool cultures. Thereafter, antibacterial therapy improved his symptoms and increased the inflammatory response. After his hospital discharge, the skin on his fingers showed desquamation like that of KD. Y. pseudotuberculosis infection should be considered as a differential disease in KD, terminal ileitis, and appendicitis. Furthermore, its infection route and culture methods should also be carefully considered.

Sonographic assessment of infectious diseases of the gastrointestinal tract: from scanning to diagnosis

BACKGROUND

Sonography of the gastrointestinal (GI) tract is a practical, safe, inexpensive, and reproducible diagnostic tool for the evaluation, diagnosis, and follow-up of infectious bowel disease. The modality is rapidly gaining prominence among clinicians on a global scale. In the United States, however, ultrasound of the bowel remains underutilized primarily due to insufficient experience among radiologists and sonographers in performing sonographic bowel assessment. This lack of experience and knowledge results in misinterpretations, missed diagnoses, and underutilization of this modality in patients with acute abdomen, with the majority of GI pathology on sonography discovered incidentally.

OBJECTIVES

This article aims to demonstrate the characteristic sonographic findings associated with GI infectious processes as well as provide dedicated ultrasound protocols for evaluation of the GI tract.

CONCLUSION

This article serves a twofold purpose, raising awareness of the utility of this imaging modality within the radiology community and also providing practical teaching points for sonographic evaluation of infectious disorders of the GI tract.

Acute kidney injury associated with Yersinia pseudotuberculosis infection: Forgotten but not gone

Background

Yersinia pseudotuberculosis is known to cause fever, gastroenteritis, or acute kidney injury (AKI). There have been several Y. pseudotuberculosis infection outbreaks to date associated with ingestion of contaminated food or unsterile water. While this disease was considered to have practically been eradicated with the improvement in public health, we encountered several cases of AKI associated with Yersinia infection.

Methods

We retrospectively collected data from medical records of patients with suspected Y. pseudotuberculosis infection who visited Seoul National University Children's Hospital in 2017.

Results

There were nine suspected cases of Yersinia infection (six males and three females; age range 2.99-12.18 years). Among them, five cases occurred in May, and seven patients were residing in the metropolitan Seoul area. Three patients had history of drinking mountain water. Every patient first presented with fever for a median of 13 days, followed by gastrointestinal symptoms and oliguria. Imaging studies revealed mesenteric lymphadenitis, terminal ileum wall thickening, and increased renal parenchymal echogenicity. Creatinine levels increased to 5.72 ± 2.18 mg/dL. Urinalysis revealed sterile pyuria, proteinuria, and glycosuria. Oliguria continued for 4 to 17 days, and two patients required dialysis; however, all of them recovered from AKI. Mucocutaneous manifestations developed later. In the diagnostic work-up, Yersinia was isolated from the stool culture in one patient. Anti-Yersinia immunoglobulin (Ig) A and IgG were positive in 6 patients.

Conclusion

Y. pseudotuberculosis infection is an infrequent cause of interstitial nephritis presenting with AKI. When a patient presents with fever, gastroenteritis, and AKI not resolving despite hydration, the clinician should suspect Y. pseudotuberculosis infection.

Point-of-Care Ultrasonography for Appendicitis Uncovers Two Alternate Diagnoses

We present two cases of pediatric patients initially presenting with a clinical suspicion of acute appendicitis. In these cases, point-of-care ultrasonography was performed early in the patient's emergency department course, leading to alternate diagnoses. This article highlights a role for point-of-care ultrasound in the diagnoses of two alternate conditions that clinically mimic appendicitis: Meckel diverticulitis and acute ileocecitis. We offer a brief overview of terminology, relevant literature, and ultrasound scanning technique for the right-lower-quadrant point-of-care ultrasound evaluation.

Sonography of acute appendicitis and its mimics in children

The diagnosis of acute right lower quadrant pain in a pediatric population is challenging. Acute appendicitis is the most common cause of an acute surgical abdomen. The common mimics of acute appendicitis are acute gastrointestinal and gynecologic diseases. This article reviews the sonographic findings of the spectrum of common acute abdominal emergencies in children with a focus on imaging clues to a specific diagnosis. This awareness can impact on diagnostic accuracy and impact patient management.

An emergency diagnostic dilemma: a case of Yersinia enterocolitica colitis mimicking acute appendicitis in a beta-thalassemia major patient: the role of CT and literature review

The role of computed tomography (CT) scanning in a case of Yersinia enterocolitica (YE) enteritis mimicking acute appendicitis in a 34-year-old female patient with beta-thalassemia major is presented. Although the abdominal CT findings on admittance were indicative of acute appendicitis (enlargement of the appendix and thickening of its wall), making appendectomy a likely treatment option, a second CT scan 3 days later was diagnostic for infectious colitis (bowel wall thickening, ulcerations of the colonic mucosa, and fat stranding), and an unnecessary appendectomy was thus avoided. The diagnosis of YE colitis was later confirmed by serology tests.

Ileítis terminal por Yersinia enterocolitica en lactantes

Yersinia enterocolitica infection presents a wide clinical spectrum; in infants and young children it usually presents as uncomplicated acute diarrhea, while in older children and adolescents it more frequently presents as terminal ileitis and/or mesenteric adenitis. We describe two infants who developed terminal ileitis complicating Y. enterocolitica infection, which is exceptionally rare. The clinical, laboratory and radiologic findings are described and ultrasound study is emphasized as a simple and reliable tool for investigation of terminal ileitis.

Contrast-enhanced power Doppler US in the diagnosis of acute appendicitis

INTRODUCTION/OBJECTIVE

To determine the value of power Doppler (PD) ultrasonography (US) and contrast-enhanced power Doppler (CEPD) US in the diagnosis of acute appendicitis and the prediction of histopathologic stages.

METHODS AND MATERIAL

50 patients with suspected acute appendicitis were evaluated by the same radiologist with PD US and CEPD US. Air micro bubbles stabilized by a granulate of "galactose and palmitic acid" were used as a contrast medium for sonography with the concentration of 400 mg/ml. PD US and CEPD US results were later correlated with the surgical and histopathologic findings. PD US and CEPD US findings were considered positive for appendicitis; if there was depiction of hyperemia in the wall of the appendix or if there was depiction of prominent peripheral vascularity when compared with normal soft tissues; and negative if both hyperemia and peripheral hyperemia were not prominent.

RESULTS AND DISCUSSIONS

Of the 50 patients, 35 patients had histopathologically proven acute appendicitis. CEPD US showed prominent hyperemia in the appendiceal vessels or feeding vessels of the inflamed appendix, and resistance index (RI) calculations were easier. There was statistically significant difference between mean RI values of the normal appendix, suppurative appendicitis and gangrenous appendicitis. PD US has accuracy of 80%, sensitivity of 74% and CEPD US has 98%, and 100% in the diagnosis of acute appendicitis. CEPD US identified 100% of suppurative appendicitis and gangrenous appendicitis.

CONCLUSION

CEPD US is a promising method in the diagnosis of acute appendicitis and determination of the inflammation stage.

Acute appendicitis mimicking infectious enteritis: diagnostic value of sonography

OBJECTIVE

To verify the role of sonography in screening of acute appendicitis in patients admitted to an infectious disease unit for suspected acute infectious enteritis.

METHODS

One hundred eighty consecutive patients (102 male and 78 female; age range, 5-72 years; mean age, 31 years) admitted for suspected infectious enteritis or typhoid fever were prospectively studied with abdominal sonography within 48 hours after admission. None of the patients had peritoneal irritation. Forty-six patients (25%) had white blood cell counts of more than 10,000/mm3 (range, 10,300-18,000/mm3). The diagnosis of acute appendicitis was made when a detectable appendix with an anteroposterior diameter of greater than 7 mm could be seen on sonography.

RESULTS

Eleven (6%) of 180 patients had thickened appendixes (anteroposterior diameter range, 7-14 mm); 2 of them had periappendiceal abscesses. Four (36%) of 11 patients with acute appendicitis had high white blood cell counts. All sonographic diagnoses of acute appendicitis and periappendiceal abscesses were confirmed at surgery. Sonography ruled out acute appendicitis in 169 patients. In all of them, clinical and sonographic follow-up excluded the diagnosis of acute appendicitis. Normal appendixes were shown on sonography in 38 (22%) of 169 cases and were not detectable in 131 (78%) of 169.

CONCLUSIONS

Sonography of the appendix is a useful method for early assessment of acute appendicitis in patients thought to have enteritis or typhoid fever.

Ultrasonographic findings correspond to clinical, endoscopic, and histologic findings in inflammatory bowel disease and other enterocolitides

OBJECTIVE

To compare results obtained by abdominal ultrasonography with clinical findings, including endoscopic and histologic findings, to evaluate the location and activity of inflammatory bowel disease, including disease controls in children.

METHODS

Ninety-two ultrasonographic scans and 41 colonoscopic examinations with biopsies were performed in 78 patients (1 month to 17.8 years of age) with Crohn's disease (n = 26), ulcerative colitis (n = 21), inflammatory bowel disease of indeterminate type (n = 2), and disease controls (other intestinal disorders, including infectious and ischemic lesions; n = 29). Laboratory parameters for inflammatory bowel disease were determined, and disease activity was assessed by a combination of clinical and laboratory data. Bowel wall thickness and echo texture were recorded in a standardized way by ultrasonography and compared with endoscopic and histologic findings in a segment-by-segment comparison.

RESULTS

Sensitivity and specificity of ultrasonography in detecting patients with severe macroscopic lesions depicted on endoscopy were 77% and 83%, respectively. Sensitivity and specificity of ultrasonography in detecting patients with severe histologic inflammation were 75% and 82%. There was a statistically significant correlation between maximal bowel wall thickness and disease activity score (P < .01).

CONCLUSIONS

Abdominal ultrasonography may be helpful in evaluating the location, severity, and inflammatory activity of inflammatory bowel disease in children and young adults.

Acute terminal ileitis, yersiniosis, and Crohn's disease: a long-term follow-up study of the relationships

Background: During the past decade, very little has been published on the relationships between Yersinia enterocolitica, acute terminal ileitis (ATI), and Crohn's disease, possibly due to a decrease in Yersinia infections and, consequently, in ATI. Methods: Fifty-three patients admitted to Herlev University Hospital during the period 1976-1998 were diagnosed as having ATI while undergoing surgery for suspected acute appendicitis. The patients were followed up, and both Yersinia titers and the development of Crohn's disease were registered. Results: Forty-four patients (83%) were tested for Yersinia, 17 of whom (39%; 95% confidence limits, 24-55%) were positive. The incidence of yersiniosis in ATI decreased significantly during the observation period (P<0.05), whereas the incidence of ATI itself was unchanged. Thirteen of the 53 patients (25%; 95% confidence limits, 14-38%) had, in addition to ATI, an inflamed appendix. Three patients developed Crohn's disease during a median observation period of 13 years (cumulative risk 6.1%). None of them had yersiniosis. Conclusions: The incidence of ATI remained stable during the observation period, even though the number of Yersinia infections decreased. This may have been due to an increase in gastrointestinal infections caused by other enteric pathogens. In accordance with previous findings, ATI patients who developed Crohn's disease did not have yersiniosis. Thus, it is still of prognostic value to test patients with ATI for Yersinia and perhaps for other enteric pathogens as well.

Colour Doppler ultrasound for the evaluation of bowel wall thickening

We performed colour Doppler ultrasound to evaluate bowel wall thickening and to determine the effectiveness of this modality. 42 patients (aged 8-83 years old, mean age 43.5 years) with bowel disease underwent both grey scale and colour Doppler ultrasound examinations. The diagnoses were classified into three categories: inflammation, vasculitis or ischaemia. The bowel wall thickness, wall echotexture and location of the involved portion were all recorded by grey scale ultrasound, while the presence of an intramural colour Doppler flow and arterial signal was evaluated by colour Doppler ultrasound. The colour Doppler flow was graded as "absent", "mild", or "abundant", and the resistive index was also calculated. Bowel wall thickening was observed in the bowel diseases demonstrating inflammation, vasculitis and ischaemia. Patients with ischaemia were significantly older than those with inflammation. The difference in bowel wall thickness was not significant among the disease categories. Differences in bowel wall echotexture, colour Doppler flow, arterial signal and resistive index among the disease categories were significant. The absence of a colour Doppler flow and of an arterial signal suggested ischaemia, while in younger patients, an abundant colour Doppler flow and a stratified echotexture suggested inflammation. The mean resistive index in the ischemic group was significantly higher than that in the inflammatory group. In conclusion, both grey scale and colour Doppler ultrasound are considered to provide useful information for evaluating and differentiating bowel wall thickening in various bowel diseases.

Trends in pediatric emergency imaging

Abdominal pain, respiratory infections, and skeletal trauma are among the most common reasons for imaging infants and children in the emergency department. The types of pathology and the imaging findings for the various causes of these conditions often differ significantly from those seen in adults with similar symptoms. Although radiographs remain the primary imaging tool, ultrasound, helical CT, and MR imaging play an increasingly important role in solving diagnostic problems in emergency pediatrics. This article highlights some of the common diagnostic dilemmas and discusses current trends in the use of advanced imaging in pediatric patients.

Role of ultrasonography in the diagnosis of postsurgical recurrence of Crohn's disease

OBJECTIVE

Ultrasonography is a valid tool in the diagnosis of Crohn's disease, but its sensitivity, specificity, and overall accuracy in the diagnosis of postoperative recurrence are still not well established. The aim of this study was to evaluate the accuracy of ultrasonography compared with endoscopy in the diagnosis of postoperative recurrence of Crohn's disease.

METHODS

Forty-seven patients resected for Crohn's ileitis were studied by ultrasonography and colonoscopy to detect possible recurrence of the disease; 10 patients operated on for cancer of the right colon were used as controls. Six patients with Crohn's disease were excluded from the study because of failure to endoscopically reach the anastomosis; the remaining 41 patients had both ultrasonography and colonoscopy over a period of 14 days. Sonographic recurrence was defined as the presence of >5 mm thickness of the ileal wall.

RESULTS

Sensitivity, specificity, and overall accuracy of ultrasonography in diagnosis of postoperative recurrence were 81%, 86%, and 83% respectively. Positive predictive value was 96% and negative predictive value was 57%.

CONCLUSION

This study is the first to assess the role of ultrasonography in comparison with endoscopy in detecting Crohn's disease recurrence after surgery. Our data suggest that ultrasonography should be used first in the case of clinical suspicion of Crohn's disease recurrence, reserving ileocolonoscopy for negative or uncertain cases.

Ultrasound examination of the small bowel: comparison with enteroclysis in patients with Crohn disease

BACKGROUND

Screening for inflammatory small bowel disease has hereto relied on barium examination, usually performed after duodenal intubation. A noninvasive technique for imaging of the small bowel in such patients would be preferable.

METHODS

A total of 59 patients were included in the study. A small bowel barium examination (SBE) was performed after duodenal intubation using a barium and air double-contrast technique. Ultrasound (US) of the right lower quadrant was performed with a 3.5- or 5-MHz transducer. The patients fasted overnight.

RESULTS

In 37 of 39 patients with a normal SBE, US was also normal. In 20 patients, SBE showed lesions compatible with Crohn disease and in 18 of these the US study showed thickening of the bowel wall. One of these patients later tested positive for Yersinia enterocolitica. There were two false-positive and two false-negative US examinations. For detection of inflammatory disease of the small bowel, US was calculated to have a sensitivity of 0.95, specificity of 0.93, accuracy of 0.93, predictive value of a positive test was 0.90, and a predictive value of a negative test was 0.95.

CONCLUSIONS

US, therefore, seems to be a reliable method in the workup of patients suspected of having inflammatory small bowel disease. Thereby, US probably can select patients for SBF.

Transabdominal US staging of gastric cancer

Penetration of gastric cancer through the wall is important because the treatment modality and prognosis are accordingly different. A prospective study was performed to assess the value of transabdominal ultrasonography in the differentiation of early gastric cancer limited within the mucosa and submucosa from advanced cancer extending into the muscle layer. Fifteen patients with early gastric cancer and 29 patients with advanced gastric cancer were evaluated preoperatively and compared with histological findings. Patients were referred after endoscopy and sonologists were informed of the site of the gastric lesions. Patients ingested 600-800 ml of boiled water and transabdominal ultrasonography of the gastric lesion was accomplished using a commercially available ultrasound equipment with 5.0 and 3.5 MHz transducers. Using the intact middle hyperechoic layer on sonogram as the criterion for early cancer, 10 of 15 patients with early gastric cancer and 27 of 29 patients with advanced gastric cancer were correctly diagnosed (84%). Fourteen of 15 cases with early gastric cancer showed a thickness of the lesion below 1.0 cm, while seven of 29 cases with advanced cancer showed a thickness 1.0 cm or less. We believe that transabdominal sonography may be a valuable method in the differentiation between early and advanced gastric cancer.