Download - Yersinia Infection 02.10.2012
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MORNING REPORT
Liset Olarte MD, PGY2
February 10, 2012
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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
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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.
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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
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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
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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.
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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.
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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.
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YERSINIA INFECTION
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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.
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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.
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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.
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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)
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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
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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%.
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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.
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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)
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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