Yersinia Pseudotuberculosis


Article Author:
Mark Brady


Article Editor:
Fatima Anjum


Editors In Chief:
Sebastiano Cassaro
Joseph Lee
Tanya Egodage


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
2/5/2019 9:47:15 PM

Introduction

Yersinia pseudotuberculosis is a rare Yersinia species. Yersinia pseudotuberculosis is associated with food-borne infection in humans. Yersinia pseudotuberculosis is characterized by a self-limited mesenteric lymphadenitis that mimics appendicitis. Yersinia pseudotuberculosis survives intracellularly. The primary virulence factor is a plasmid-encoded protein that causes increased invasiveness. Postinfectious complications include reactive arthritis and erythema nodosum. The triad for Yersinia pseudotuberculosis includes abdominal pain, fever, and rash. Rarely, it has been associated with sepsis.[1][2][3]

Etiology

United States

  • No specific pattern of Yersinia pseudotuberculosis infection has been reported. Most Yersinia outbreaks have been associated with Yersinia enterocolitica rather than Yersinia pseudotuberculosis.

International

  • The distribution of Yersinia pseudotuberculosis infection is worldwide. Most cases occur in winter due to enhanced growth characteristics in cold temperatures.

Mortality/Morbidity

  • Yersinia pseudotuberculosis has a low case-fatality rate. However, the rare sepsis-associated illnesses caused by Y. pseudotuberculosis infection in patients with chronic liver disease has a mortality rate that exceeds 75%.

Race

  • Yersinia pseudotuberculosis infection has no specific racial or ethnic predilection.

Sex

  • Yersinia pseudotuberculosis infection is more common in men than in women. The postinfectious complications of arthritis and erythema nodosum are more common in women than in men.

Age

  • Seventy-five percent or more of patients with Yersinia pseudotuberculosis infection are ages five to 15 years.

Epidemiology

Yersinia pseudotuberculosis infection is usually acquired through the gastrointestinal tract after consumption of contaminated foods. Yersinia pseudotuberculosis infections do not typically cause diarrheal symptoms; they can cause mesenteric lymphadenitis, granulomatous disease, and dissemination with sepsis.[4]

  • Patients with Yersinia pseudotuberculosis and iron-overload states such as hemochromatosis, venous congestion, hemolytic anemia, and cirrhosis are at risk for sepsis.
  • 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.

Pathophysiology

One usually acquires Yersinia pseudotuberculosis from the gastrointestinal (GI) tract after consumption of contaminated food. A large inoculum is usually required to produce disease. Since Yersinia pseudotuberculosis does not generate iron chelating substances, patients with iron overload disorders like venous congestion, hemochromatosis, cirrhosis and hemolytic anemias are at a slightly higher risk for systemic infections.[5]

Histopathology

In general, the appendix will appear normal, but the nearby mesenteric lymph nodes may show epitheliod granulomatous lesions, coagulative necrosis, and lymphoid hyperplasia. The small bowel may develop microabscesses, cryptic hyperplasia, and shortening of villi.

History and Physical

Symptoms caused by Yersinia pseudotuberculosis infection include abdominal pain and fever. The abdominal pain is often right lower quadrant in location and may mimic appendicitis. Diarrhea is uncommon. Late complications of Yersinia pseudotuberculosis infection include reactive arthritis and rheumatologic manifestations.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.Other manifestations include erythema nodosum, arthralgias, reactive arthritis, ankylosing spondylitis, and lumbar facet joint disease.A fever and rash involving the head and neck, upper and lower extremity erythema, mucous membrane enanthem, and strawberry tongue may occur.

Yersinia pseudotuberculosis infection is associated with ingestion of contaminated food items, including fresh produce.

Physical findings caused by Yersinia pseudotuberculosis infection may be grouped into three main categories: systemic, enteric, and rheumatologic.

  • Systemic findings include fever, skin rash, strawberry tongue, hypotension, and lymphadenopathy
  • Enteric findings include abdominal tenderness with or without rebound and tenderness over McBurney point
  • Rheumatologic involvement includes joint effusion, tenderness, or decreased the range of movement and may be asymmetric in distribution
  • Erythema nodosum lesions may be found
  • A sporotrichoid pattern of disease has been associated with Yersinia pseudotuberculosis infection
  • Ophthalmic findings such as uveitis and conjunctivitis have also been reported.

Evaluation

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.[6][7]Microbiology

  • Yersinia pseudotuberculosis has two pathogenic species that infect humans: Yersinia enterocolitica and Yersinia pestis
  • Yersinia pseudotuberculosis is a gram-negative, non-lactose-fermenting Coccobacillus that differentiated by its fermentation of sorbitol and ornithine decarboxylase activity, among other features. The optimum growth occurs on MacConkey medium at 20 C to 35 C. The organism is urease-positive.

Bacteriology

  • Yersinia pseudotuberculosis is aerobic and facultatively anaerobic; it is a gram-negative coccobacillus and grows slowly on blood and chocolate agar plates. It forms small gray and translucent colonies at 24 to 72 hours. It has a good growth pattern on MacConkey or eosin-methylene blue agar plates but is enhanced noticeably at a temperature lower than 28 C it will be motile. Yersinia pseudotuberculosis is oxidase-negative, catalase-producing, and urea-splitting, and does not ferment lactose.

Stool

  • Isolation from stool is difficult given the slow growth pattern. Stool culture yield may be increased with cold enrichment, special culture media, or alkali treatment.

Blood, Peritoneal and Synovial Fluids, and Pharyngeal Exudate

  • Might yield Yersinia pseudotuberculosis

Serology

  • Enzyme-linked immunosorbent assay and agglutination tests may be obtained; the antibodies (against the O antigen) may appear soon after the onset of illness and wane over two to six months. Hemagglutination reaction tests that detect the pili of either Yersinia pseudotuberculosis or Yersinia pestis have been developed. Hemagglutination titers of 1:160 or higher suggest a true infection.
  • Cross-reaction between antibodies with other organisms may obscure the diagnostic picture. These other organisms include other Yersinia, Brucella, Vibrio, Rickettsia, and Salmonella.
  • Sodium dodecyl sulfate-polyacrylamide gel electrophoresis is a reliable serologic procedure for the diagnosis of Yersinia pseudotuberculosis or Yersinia enterocolitica infection.

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.

Treatment / Management

Yersinia pseudotuberculosis infection is usually self-limited. More toxic presentations, including septic syndromes or severe dehydration, may require hospitalization. General supportive care is needed.[8][9]

Exploratory laparotomy may be warranted in patients with complications such as severe abdominal pain, including acute abdominal presentations, peritoneal findings, or, uncommonly, intussusception. However, this intervention is not common.

Differential Diagnosis

  • Appendicitis
  • Sepsis
  • Pancreatitis
  • Inflammatory bowel disease
  • Gastroenteritis
  • Toxic shock syndrome
  • Leptospirosis

Complications

  • Septic arthritis
  • Mesenteric adenitis
  • Intussusception

Postoperative and Rehabilitation Care

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.

Consultations

Gastroenterologist

Infectious disease

Surgeon

Deterrence and Patient Education

The patient should be educated on food hygiene and the fact that the organism is cold tolerant. 

One should always cook pig related product well.

Pearls and Other Issues

Consult infectious disease, gastroenterology, or surgery if invasive diagnostic or therapeutic interventions are warranted. For unusual presentations, rheumatologic, dermatologic, or ocular complications; additional consultation should be considered.

Enhancing Healthcare Team Outcomes

Yersinia pseudotuberculosis is caused by a cold-tolerant bacteria and is a common cause of foodborne disease. It can present with enterocolitis or pseudoappendicitis. Even though the mortality rate is low in healthy people, it can be fatal in immunocompromised individuals. Because it is a foodborne disorder, an interprofessional approach is vital. 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 myriad signs and symptoms of the infection so that the patient seeks prompt care.

Because the infection can mimic many other disorders, consultation with a surgeon, an infectious disease expert and a gastroenterologist should be sought.[10][8] (Level III)

Outcomes

The majority of cases of Yersinia pseudotuberculosis are mild and self-limited. Some patients may develop severe disease that can lead to sepsis and generalized involvement of the intestine. In immunocompromised patients, the disease can be fatal.[11][12] (Level III)


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Yersinia Pseudotuberculosis - Questions

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Iron supplementation can increase the pathogenicity of which organism?



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A patient presents with right lower quadrant pain, fever, and a rash. The CT scan and ultrasound are negative for appendicitis. Which of the following would not be an expected finding?



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In regards to Yersinia pseudotuberculosis, which of the following laboratory findings is inconsistent with expectations?



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A 6-year-old child is suspected of being infected with Yersinia pseudotuberculosis. Which of the following is true?



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Yersinia Pseudotuberculosis - References

References

Yang X,Pan J,Wang Y,Shen X, Type VI Secretion Systems Present New Insights on Pathogenic {i}Yersinia{/i}. Frontiers in cellular and infection microbiology. 2018     [PubMed]
Davis KM, All {i}Yersinia{/i} Are Not Created Equal: Phenotypic Adaptation to Distinct Niches Within Mammalian Tissues. Frontiers in cellular and infection microbiology. 2018     [PubMed]
Atkinson S,Williams P, Yersinia virulence factors - a sophisticated arsenal for combating host defences. F1000Research. 2016     [PubMed]
Reinhardt M,Hammerl JA,Kunz K,Barac A,Nöckler K,Hertwig S, Prevalence and diversity of {i}Yersinia pseudotuberculosis{/i} in Wild Boars in Northeast Germany. Applied and environmental microbiology. 2018 Jul 6     [PubMed]
Stanger KJ,McGregor H,Larsen J, Outbreaks of diarrhoea ('winter scours') in weaned Merino sheep in south-eastern Australia. Australian veterinary journal. 2018 May     [PubMed]
Keto-Timonen R,Hietala N,Palonen E,Hakakorpi A,Lindström M,Korkeala H, Cold Shock Proteins: A Minireview with Special Emphasis on Csp-family of Enteropathogenic Yersinia. Frontiers in microbiology. 2016     [PubMed]
Chauhan N,Wrobel A,Skurnik M,Leo JC, Yersinia adhesins: An arsenal for infection. Proteomics. Clinical applications. 2016 Oct     [PubMed]
Woodman I,Schofield JB,Haboubi N, The histopathological mimics of inflammatory bowel disease: a critical appraisal. Techniques in coloproctology. 2015 Dec     [PubMed]
May AN,Piper SM,Boutlis CS, Yersinia intussusception: case report and review. Journal of paediatrics and child health. 2014 Feb     [PubMed]
Kaasch AJ,Dinter J,Goeser T,Plum G,Seifert H, Yersinia pseudotuberculosis bloodstream infection and septic arthritis: case report and review of the literature. Infection. 2012 Apr     [PubMed]
Ansong C,Schrimpe-Rutledge AC,Mitchell HD,Chauhan S,Jones MB,Kim YM,McAteer K,Deatherage Kaiser BL,Dubois JL,Brewer HM,Frank BC,McDermott JE,Metz TO,Peterson SN,Smith RD,Motin VL,Adkins JN, A multi-omic systems approach to elucidating Yersinia virulence mechanisms. Molecular bioSystems. 2013 Jan 27     [PubMed]
Naktin J,Beavis KG, Yersinia enterocolitica and Yersinia pseudotuberculosis. Clinics in laboratory medicine. 1999 Sep     [PubMed]

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