THE JOHNS HOPKINS MICROBIOLOGY NESLETTER Vol. 28, No. 04

Tuesday, March 15, 2011

A.Health Alert Network, Maryland Department of Health and Mental Hygiene

There is no information available at this time.

B.The Johns Hopkins Hospital, Department of Pathology, Information provided by,

Hillary Elwood, MD

Clinical Presentation:

An 11 month old African American female was brought to her primary care physician with complaints of low grade fever, non-bloody diarrhea and intermittent vomiting for 3 days. The child has no significant prior medical history, her diet consists of formula and pureed food and she has had no recent ill contacts. Of note, 7 days prior to presentation, the family had a holiday meal that included chitterlings (cooked pig intestines); the infant did not eat the chitterlings but was given formula by a relative who had been cleaning and preparing the food. As part of the work-up, a stool bacterial culture was sent which eventually grew Yersiniaenterocolitica. The city health department was notified. A sample was sent to the state department and the diagnosis was verified. The family was instructed in proper food preparation and hand washing and the patient recovered with supportive care.

Organism:

Yersiniaenterocoliticais a gram negative bacillus that is widely distributed in aquatic and animal reservoirs, with swine serving as the major reservoir for human pathogenic strains. It is the most common species of Yersiniarecovered from clinical specimens. Y. enterocolitica grows on MacConkey agar but is a non-lactose fermenter. There are six biovars and over 50 serogroups of Y. enterocolitica; however only five are considered pathogenic for humans. Most of the cases in the USA and Canada are serotypes O:3 and O:8 whereas in Europe O:3 and O:9 predominate.

Clinical Significance:

Y. enterocolitica enters humans through the oral digestive route and can cause terminal ileitis, lymphadenitis and acute enterocolitis. Acute gastroenteritis from Yersinia is marked by diarrhea, abdominal pain, fever and, less frequently, nausea and vomiting; occasionally, the pain is noted as entirely “right-sided” and the mistaken diagnosis of appendicitis may be rendered. Secondary manifestations of erythemanodosum, polyarthritis and, uncommonly, septicemia and endocarditis, have been reported. Septicemia with Y. enterocolitica occurs almost exclusively in patients with iron overload (such as B-thalassemia patients) or those on the iron-chelating agent deferoxamine. Y. enterocolitica has also been isolated from contaminated red blood cell units following septic transfusion reactions. The association of Y. enterocolitica with household preparation of chitterlings has been established and outbreaks are most common during the winter months when chitterlings are often prepared as part of holiday meals.

Laboratory Diagnosis:

In the microbiology laboratory at The Johns Hopkins Hospital, stool specimens are plated onto specialized media to select and distinguish stool pathogens from normal flora.. One such agar is Cefsu3.lodin-Irgasin-Novobiocin (CIN) agar which selects for Yersiniasp. These plates are kept at room temperature as Yersiniasp.grow best at room temperature or below. Yersinia typically forms a pink colony on the CIN agar; these colonies are then subjected to triple sugar iron (TSI) and citrate testing. If the citrate testing is negative (indicating organism does not use citrate) and the TSI shows some evidence of fermentation, a presumptive diagnosis of Yersiniaenterocolitica is made. Automated laboratory methods are then used for confirmatory testing and antibiotic susceptibility.

Treatment:

There are no controlled trials that indicate that antimicrobial treatment of acute Yersiniaenterocolitica associated enterocolitis is beneficial. A retrospective case series from Norway showed that treatment was not associated with a decreased duration of illness. There also was no clinical benefit from a small prospective placebo-controlled trial of trimethoprim-sulfamethoxazole in Canadian children. Most cases of Yersiniaenterocolitis do not merit treatment; however, in cases of clinical severity or an underlying condition of the patient, a fluoroquinolone or trimethoprim-sulfamethoxazole is sometimes used.

Prevention of Yersinia infection includes safe food preparation and hand washing. The most common food vehicles for Yersinia infection are pork or pork products, particularly chitterlings. A common route of transmission to infant and children is indirect via the hands of the person handling the raw food. Persons preparing pork should be counseled to wash hands, cutting boards and utensils immediately after handling raw meat and they should avoid eating undercooked pork.

References:

  1. Lee LA, Gerber R, et al. Yersiniaenterocolitica 0:3 infections in infants and children, associated with the household preparation of chitterlings. NEJM 1990;322(14):984-987.
  2. Tribe Yersinieae. In: Winn W, allen S, Janda W, et al, eds. Koneman’s Color Atlas and Textbook of Diagnostic Microbiology, 6th Ed. Baltimore: Lippincott Williams & Wilkins, 2006:268-274.
  3. Huovinen E, Sihvonen LM, et al. Symptoms and sources of Yersiniaenterocolitica-infection: a case-control study. BMC Infectious Diseases 2010;10.
  4. Ostroff SM, Kapperud G, et al. Clinical features of sporadic Yersiniaenterocolitica infections in Norway. J Infect Dis 1992;166(4):812-7.
  5. Pai CH, Gillis F, et al. Placebo-controlled double-blind evaluation of trimethoprim-sulfamethoxazole treatment of Yersiniaenterocolitica gastroenteritis. J Pediatr 1984;104(2):308-11.