Yersinia enterocolitica infection in patients with acute surgical abdominal disease. A prospective study

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.

Another mistaken case of appendicitis

In 2010, when I was 17, I presented to hospital with progressive discomfort and pain in the right iliac fossa when eating and moving, associated with mild fever and diarrhoea. Appendicitis was suspected but immediate surgery was deferred, as the inflammatory markers did not adequately support the clinical diagnosis of appendicitis. Further tests, including MRI, were then undertaken. The MRI showed evidence of terminal ileitis and a normal appendix. Crohn's disease was considered as part of the differential diagnosis. However, a Yersinia enterocolitica infection was subsequently confirmed. The episode highlighted several learning points including preventing unnecessary surgery and the advantages of using a multidisciplinary approach involving imaging the abdomen and microbiological input.

[An outbreak of appendectomies in La Désirade, Guadeloupe, August 1995-July 1996]

BACKGROUND

In October 1995, over 50 cases of appendectomies among the 1.605 residents of the island La Désirade (Guadeloupe) were reported by the only island clinician to the local health authority. We describe the outbreak investigations which were implemented in order to describe the phenomenon and generate hypotheses on its cause.

METHODS

An exhaustive case finding of residents having undergone appendectomy between 10 August 1995 and 22 July 1996 was conducted. We reviewed the medical charts of the cases; read pathology slides; interviewed cases and their families to retrieve detailed clinical history; studied the prevalence of markers of infection and of stool pathogens and analysed water supply quality data.

RESULTS

We identified 226 cases of appendectomy (14% of the island population), 40% in May-June 1996, 46% in males and 40% under 15 years of age. Clinical, biological and pathological findings were heterogeneous and did not support the hypothesis of an outbreak of appendicitis. The study of abdominal symptoms in the families of the cases did not support person to person transmission but revealed frequent, subacute or chronic abdominal complaints. The analysis of markers of infection or of stool bacteria and parasites in a self selected sample of the island population was not suggestive. Water supply did not show any bacterial or chemical contamination.

CONCLUSION

The investigation of a large outbreak of appendectomies was unable to find a single infectious or toxic origin to a high prevalence of chronic abdominal symptoms in an isolated population. An inappropriate medical answer in an isolated population probably turned heterogeneous complaints into an outbreak with major public health consequences.

Yersinia enterocolitis mimicking Crohn's disease in a toddler

A 31/2-year-old girl presented with persistent abdominal pain, fever, vomiting, and diarrhea accompanied by rash, oral ulceration, anemia, and an elevated sedimentation rate. Initial evaluation revealed no pathogens and was extended to include abdominal ultrasound and computed tomography showing marked ileocecal edema and mesenteric adenopathy. Colonoscopy revealed focal ulceration from rectum to cecum with histology of severe active colitis with mild chronic changes. Enteroclysis demonstrated a nodular, edematous terminal ileum. Because of the patient's clinical deterioration despite antibiotics, these features were construed consistent with Crohn's disease, and glucocorticoid therapy was begun. By the ninth hospital day, admission cultures grew Yersinia enterocolitica, and trimethoprim/sulfamethoxazole was begun followed by prompt clinical improvement. The delay in diagnosis afforded an unusually comprehensive clinical description of the presentation and diagnosis of Yersinia enterocolitis in childhood.

Prevalence of antibodies to Yersinia enterocolitica O:3 among Norwegian military recruits: association with risk factors and clinical manifestations

IgG antibody activity to Yersinia enterocolitica serogroup O:3 was detected in sera from 56 (7.4%) of 755 Norwegian military recruits, using an enzyme-linked immunosorbent assay. The highest prevalence was found among recruits from Oslo city (12/56, 21.4%). The recruits answered a questionnaire which covered demographic data, specific exposures, and clinical information. The following risk factors were found to be independently associated with IgG activity in logistic regression analysis: receiving drinking water from a private well (odds ratio (OR) = 3.40; p = 0.004), being a resident of Oslo city (OR = 2.99; p = 0.006), and living in eastern Norway (OR = 2.25; p = 0.015). By univariate analysis, living in an urban area was associated with IgG activity, but this factor did not independently affect risk. Present or previous contact with animals, including pigs, and travels abroad were not associated with an increased risk. Yersinia enterocolitica O:3 seropositive recruits were more likely to report previous surgery for suspected appendicitis than seronegative individuals (OR = 4.26; p = 0.0024). Among recruits with previous appendectomy, mesenteric lymphadenitis as the sole peroperative finding was more common in patients with IgG activity to Y. enterocolitica O:3 (4/7) than in seronegative patients (1/19) (p = 0.01). Recurrent diarrhea, steatorrhea or joint complaints were not associated with antibody activity.

Acute and chronic gastrointestinal manifestations associated with Yersinia enterocolitica infection. A Norwegian 10-year follow-up study on 458 hospitalized patients

The aim of the present study was to elucidate the gastrointestinal manifestations of yersiniosis. During the period 1974 to 1983, Yersinia enterocolitica infection was diagnosed in 458 patients, by isolation from fecal samples or by antibody response. At first admission, 184 patients had abdominal pain; 200, diarrhea; 45, vomiting; and 36, weight loss. Ulcerative colitis was diagnosed in 7 patients, Crohn's disease in 2, and unspecific colitis in 11. Mesenteric lymphadenitis or ileitis were found in 43 of 56 patients at laparotomy. The patients were followed for 4 to 14 years (1987). Thirty-eight patients were readmitted with abdominal pain and 28 with diarrhea; these symptoms were significantly correlated with the corresponding symptoms at first admission. Chronic colitis was diagnosed in 4 patients, chronic weight loss in 12. A follow-up inquiry (380 patients) indicated that patients with right iliac fossa pain during the acute infection less frequently developed chronic abdominal complaints. Gastrointestinal symptoms are common in both the acute and chronic states of yersiniosis. The correlations between acute and chronic symptoms indicate that yersiniosis is a chronic disease. Immunologically competent individuals may profit by fighting the infection in the right iliac fossa. The relationship between yersiniosis and inflammatory bowel diseases may still not be settled.

Yersinia enterocolitica coxitis after hip replacement. A case report

We report a case of hematogenous Yersinia enterocolitica coxitis 10 years after hip replacement. Despite extraction of the prosthesis and antibiotic treatment, the infection relapsed. Infections in replaced joints with Yersinia enterocolitica call for long-standing treatment with specific antibiotics.

Clinical manifestations of Yersinia pseudotuberculosis infection in children

The clinical manifestations of infection were analysed during an outbreak of 34 cases of Yersinia pseudotuberculosis serotype Ia infection. The diagnosis was based on the results of enzyme immunoassay and verified by stool culture in five cases. The first four patients were pupils from the same school, and information on any signs and symptoms of infection was obtained by questionnaire from pupils of the school. A blood sample was obtained from 101 children. Strong IgM and IgG antibody responses to Yersinia pseudotuberculosis Ia were found in 13 (25%) of the 52 pupils who reported signs and symptoms of infection and in 9 (18%) of the 49 with no manifestations of infection. The vigorous immune response also resulted in effective opsonization of the causative microorganism. The most common symptoms were fever and abdominal pain. Three children operated on because of suspected appendicitis were found to have mesenteric lymphadenitis. Only one patient developed reactive arthritis. Analysis showed that a remarkable proportion of Yersinia pseudotuberculosis infections may be subclinical, and that individual Yersinia pseudotuberculosis strains may have different capacities to cause postinfection complications.

Yersinia infections in surgical practice

This article reviews the clinical manifestations of Yersinia bacteria emphasizing their recent rise in incidence and describing how Yersinia infection presents to the general surgeon. Geographical variations, patterns of disease, pathogenicity and the problems in diagnosis and management are discussed. This common but often unrecognized infection is usually self-limiting but the very young, the very old and the immunocompromised are at greater risk and prompt treatment is required to save lives.

Acute abdominal conditions in children and adolescents

Evaluation and management of the acute abdomen in childhood require a thorough familiarity with the numerous disorders that may cause abdominal emergencies. Many of these entities are rarely seen in adults or have clinical features that are very different from those observed in adults. Diagnosis is often confounded by difficulties in obtaining an accurate history and physical examination. In infants and young children, complications of various congenital abnormalities are more common causes of abdominal pain, whereas acquired disorders are observed more frequently in older children and adolescents.

Yersinia infection and acute abdominal pain

In 194 patients presenting with acute abdominal pain from whom sequential serum samples were taken, the frequency of yersiniosis, established serologically, was significantly higher (23%) than in 320 control subjects (2%). Yersiniosis occurred in 31% of patients with acute appendicitis. Acute-phase serum samples only, obtained in a further 307 patients, yielded a falsely low frequency of yersiniosis (4%). Y pseudotuberculosis was five times more common than Y enterocolitica, and Y pseudotuberculosis type IV was the most common serotype, accounting for 43% of Yersinia infections. Yersinia may play a more important part in the aetiology of acute abdominal pain, and particularly acute appendicitis, than has been previously appreciated. Antibody titres to both Y enterocolitica and Y pseudotuberculosis frequently rise late in infections causing abdominal pain. Consequently analysis of acute-phase serum samples alone leads to underdiagnosis of yersiniosis.

Yersiniosis as a gastrointestinal disease

Anti-yersinia antibodies were assessed in sera from 630 patients admitted to a department of surgery for acute abdominal disease, using an enzyme-linked immunosorbent assay (ELISA). In 21 patients a high concentration of yersinia antibodies confirmed recent yersinia infection. Eight patients had an appendicectomy performed; in all patients with antibodies against Y. enterocolitica 9 or Y. pseudotuberculosis IA a true appendicitis was found at operation. Two patients with Y. enterocolitica 3 antibodies had acute terminal ileitis and mesenterial lymphadenitis. In 4 patients a diagnosis of acute pancreatitis was established; 2 of these had cholecystitis. Two further patients had cholecystitis without pancreatic affection. Two patients had colonic diverticulitis, 1 with perforation. The results demonstrate that yersinia infection may commonly give rise to a variety of acute abdominal inflammations, and stress the importance of serological and bacteriological diagnostic procedures.

A cluster of true appendicitis cases

A cluster of cases of appendicitis occurred primarily in school-age boys in a small Texas town. The expected rate of appendicitis is 1.5 cases per 1,000 persons, or about 1 case per month in that town. However, in the spring of 1984, 13 cases, 10 in school-age boys, occurred. In eight of these patients, the initial onset of abdominal pain occurred over a 15 day period. A case controlled study of school-age patients indicated that sweets in the diet and consumption of local farm eggs may have been associated with the appendicitis. We hypothesize that a group of young male patients who were susceptible to appendicitis because of the high sugar content of their diets were exposed to a bacterium or virus that precipitated this outbreak of appendicitis.

The acute abdomen in children

Evaluation of abdominal pain in children poses a major challenge for the pediatrician and pediatric surgeon alike. Simple appendicitis remains one of the most difficult diagnoses in children. There has been an alarming increase in the incidence of perforated appendicitis, and professional delay has been found to be a factor in this increased rate. Therefore, this discussion focuses on appendicitis and its differential diagnosis.

Epidemiologic investigation of a Yersinia camp outbreak linked to a food handler

In July 1981, an outbreak of gastroenteritis occurred at a summer diet camp. Of the 455 campers and staff, 35 per cent developed an illness characterized by abdominal pain, fever, diarrhea, and/or nausea and vomiting. A total of 53 per cent experienced abdominal pain. Seven persons were hospitalized, five of whom had appendectomies. Yersinia enterocolitica serogroup 0:8 was isolated from 37 (54 per cent) of 69 persons examined, including the camp cook and three assistants. An epidemiologic investigation demonstrated that illness was associated with consumption of reconstituted powdered milk and/or chow mein . Y. enterocolitica serogroup 0:8 was subsequently isolated from milk, the milk dispenser, and leftover chow mein . Information obtained during the investigation suggested that the Yersinia had been introduced by a food handler during food-processing procedures.

The Yersinia enterocolitica infection in acute abdominal surgery. A clinical study with a 5-year follow-up period

By estimation of antibody titres or possibly isolation of the micro-organism, the role of the Yersinia enterocolitica as an etiological agent in mesenterial lymphadenitis, ileal inflammation, or abdominal colics was evaluated in 94 consecutive patients (25 operated upon and 69 treated conservatively) during a 1-year period from 1975-76. Eighty four patients (24 operated upon and 60 treated conservatively) were re-examined 5 years later. Among the 25 patients operated upon, three presented acute terminal ileitis, two of them in association with acute Y. enterocolitica infection. A substantial part of the 22 patients with other peroperative findings also presented trace or positive Y. enterocolitica antibody titres. Some of these patients experienced complaints attributable to the Y. enterocolitica infection over the following years. At re-examination, previously elevated Y. enterocolitica antibody titres had generally normalized, and in the two patients who in 1975 presented acute terminal ileitis associated with acute Y. enterocolitica infection, radiological examination now demonstrated normal terminal ileum. Among 69 patients treated conservatively for abdominal colics, 36 in 1975 presented trace or positive titres. During the 5-year follow-up period, abdominal pain and joint complaints were significantly more commonly experienced by patients with trace or positive titres than by patients with negative titres (p = 0.007 and p = 0.004, respectively). The Y. enterocolitica is an important cause of abdominal disease in our region, and the infection commonly gives symptoms of long duration.

Human Yersinia enterocolitica infections in Wisconsin. Clinical, laboratory and epidemiologic features

Yersinia enterocolitica has been sought in stool and blood culture specimens by the Wisconsin State Laboratory of Hygiene (SLH) since 1973. Clinical information on symptoms, duration of illness, and use of antibiotics for 41 persons with Y. enterocolitica infections from January 1, 1979, to September 30, 1980, was obtained by telephone interviews. Diarrhea and abdominal pain were the most common symptoms of the ill persons; extraintestinal symptoms were infrequently reported. Ten infected persons (24 percent) had no illness. Review of a 10 percent sample of all stool specimens cultured at the SLH from June 20, 1977, to June 20, 1979, revealed that Salmonella was the most commonly isolated enteric pathogen (15.4 percent) followed by Shigella (2.0 percent) and Y. enterocolitica (0.7 percent). Several different biotypes and serotypes of Y. enterocolitica were associated with illness. Y. enterocolitica isolates were uniformly susceptible to a wide variety of antibiotics, and most isolates were resistant to ampicillin. Epidemiologic studies showed that persons with Y. enterocolitica infections were more likely to live in rural counties than were all persons sending stool samples or those having Salmonella infections; underlying illness was identified as a risk factor for infection.

Differential and selective medium for isolation of Yersinia enterocolitica from stools

A new differential and selective medium, DYS agar, was developed and evaluated from the isolation of Yersinia enterocolitica. Ther bile salts content of the medium resulted in high selectivity, and inclusion of arabinose, lysine, and arginine rendered Y. Enterocolitica very distinct from Proteus spp., Pseudomonas spp., and other members of the family Enterobacteriaceae. DYS medium was more efficient for the isolation of Y. enterocolitica from experimentally inoculated fecal specimens than MacConkey, deoxycholate-citrate, and salmonella-shigella agars. Although the medium showed selectivity similar to that of another relatively new medium. Y medium (a selective medium for Y. enterocolitica containing sodium oxalate). DYS agar was found to be superior to Y medium in terms of differentiation of Y. enterocolitica from other intestinal organisms. DYS medium is simple to prepare.

Yersiniosis in children

40 cases of bacteriologically proved Yersinia enterocolitica infections in children under 15 years were reviewed. Most children presented with abdominal symptoms, and diarrhoea was present in 80% of them. In half of those with diarrhoea the stools were mucoid and gross blood was often present. Faecal leucocytes were found in 4 out of the 5 children studied. The clinical findings are consistent with the enteroinvasive pathogenic mechanism proposed for Y. enterocolitica. 29 of 30 faecal isolates of Y. enterocolitica were found invasive for human epithelial cells in vitro. Nine strains produced an enterotoxin demonstrable in newborn mouse assay. Toxin production may be an additional pathogenic mechanism in human yersiniosis.

Heat-stable enterotoxin produced by Yersinia enterocolitica isolated from patients

Twenty-three strains of Yersinia enterocolitica were isolated from children with gastrointestinal illness and examined for the production of enterotoxins by using both suckling mouse and Chinese hamster ovary (CHO) cell assay systems. Six strains were found to be enterotoxigenic in the suckling mouse assay, but all strains were negative in the CHO cell assay. Enterotoxin was detected in the culture supernatant when organisms were grown at 25 C but not at 37 C. Enterotoxin in a 15-fold concentrated culture supernatant was precipitated by adding absolute ethanol to a concentration of 90%. However, after being dialyzed against distilled water in Spectra/por 6 membrane tubing, it was soluble in 80% acetone. One unit dose of partially purified enterotoxin was 5.0 micrograms of protein/mouse in the suckling mouse assay. The molecular weight of enterotoxin was between 10,000 and 50,000 daltons as determined by ultrafiltration. It was stable to heat (121 C X 20 min or 100 C X 60 min). These observations indicated that Y. enterocolitica isolated in Japan also produce an enterotoxin similar to the heat-stable enterotoxin of Escherichia coli. However its physiochemical properties seem to be different from those of E. coli.

Studies on Yersinia enterocolitica isolated from swine and dogs

Yersinia enterocolitica serotype 03 was isolated from the colon contents of 27 (4.5%) of 599 bacon pigs on slaughter. Two (1.7%) out of 115 dogs were positive by culture for this human-athogenic serotype of Y. enterocolitica. A number of other serotypes of Y. enterocolitica were also obtained both from porcine and canine enteric contents (4b, 5a, 6, 7, 11, 12, 15, 17, 19, 26b, and non-typeable strains). All these serotypes are supposedly non-pathogenic for man and may possibly originate from the microflora of the environment. Haemolysis on bovine blood agar was observed for strains belonging to O-serotype 3.

Production of enterotoxin by Yersinia enterocolitica

Forty-three strains of Yersinia enterocolitica isolated from children with gastroenteritis and 18 laboratory strains were examined for enterotoxin production by using the infant mouse, Y1 adrenal cell, and rabbit ileal loop assay systems. All clinical isolates and seven laboratory strains were found enterotoxigenic in the infant mouse model, but none of the strains produced toxin in the Y1 adrenal cell system. One enterotoxin-producing strain was also tested by the rabbit ileal loop assay, confirming the results of the infant mouse assay. The enterotoxin was heat-stable and as active in the 6-h rabbit ileal loop as in the 18-h assay, suggesting a similarity to the heat-stable enterotoxin of Escherichia coli.

Epidemic Yersinia enterocolitica infection due to contaminated chocolate milk

In September and October, 1976, an outbreak of illness due to chocolate milk contaminated with Yersinia enterocolitica resulted in hospitalization of 36 children, 16 of whom had appendectomies. Infection with Y. enterocolitica serotype 0:8 was demonstrated in 38 ill persons. Sixty-one per cent of the persons who were infected had a titer greater than 1:160 OH agglutinins to serotype 8 yersinia, whereas 48 per cent of the hospitalized children had a fourfold change in agglutinin titer. An epidemiologic investigation demonstrated that illness was associated with drinking of chocolate milk purchased in school cafeterias, and Y. enterocolitica 0:8 was subsequently isolated from the milk. The investigation suggested that the bacterium was introduced at the dairy during the mixing by hand of chocolate syrup with previously pasteurized milk.

Fulminant septicemia caused by Yersinia enterocolitica

A lethal case of septicemia caused by Yershia enterocolitica serotype 3 is described. A 59-year-old male, previously healthy, presented with 6 weeks of fever, abdominal pains and gradual prostration ending in overhelming septicemia and death before a conclusive diagnosis was established. Necropsy showed cirrhosis, haemochromatosis and numerous abscesses in the liver.