å¡ CASE REPORT å¡ Multiple Liver Abscesses Secondary to Yersinia Enterocolitica Hiroshi Nemoto, Kyoko Murabayashi, Yuko Kawamura, Kenji Sasaki, Nobuo Wakata, Masao Kinoshita and Masaru Furube* A 37-year-old male, a poorly-controlled insulin-dependent diabetic patient, was admitted to our hospital with complaints of high fever and confusion. Laboratory data showed hyper glycemia, positive inflammatory reaction and liver dysfunction. Blood culture demonstrated Yersinia enterocolitica. Liver CT scan showed multiple low density areas. These data were consistent with a diagnosis of liver abscess secondary to Yersinia enterocolitica. He died of disseminated intravascular coagulation; subsequentwith autopsy confirmed thebut clinical diagnosis. Liver abscess secondary to Yersinia enterocolitica septicemia is rare, has been reported in compromised hosts. In the mechanism of this disease, the alimentary tract has been suggested to be the port of entry in most cases. (Internal Medicine 31: 1125-1127, 1992) Key words: sepsis, diabetes mellitus, serotype 03 antibody, hepatic encephalopathy

TIBC 119[265-370] /ig/dl, Ammonia 148[15-86] jug/dl, ICG 18[0-10]% and ketonuria (3+). Hyperglycemia and ketoacidosis were improved by We treated a case of sepsis and multiple liver ab insulin and water supplement. Spike fever and confusion scesses due to Yersinia enterocolitica (Y.E) in an insulin continued. Blood culture demonstrated the presence of dependent diabetes mellitus patient. In Japan, it is rare Y.E. (serum type 03, biological type 3B). Abdominal to find severe infection caused by Y.E., especially in CT scan (Fig. 1) showed multiple round low density adult patients. areas (2-5cm in diameter) in the bilateral lobes of the Case Report liver. Ultrasound also showed multiple clear margins around hypoechoic lesions. These data suggested liver A 37-year-old diabetic man was treated with insulin abscesses secondary to Y.E. with septicemia. Chemo for ten years, but his diabetic condition was not well therapy was started with ceftizoxime (CZX) 6g/day; controlled. On September 27, 1986, he began to suffer piperacillin (PIPC) 4 g/day was later added. Neurological from high fever and diarrhea; nausea, vomiting and mild signs (flapping tremor, confusion and dyscalculia) were disturbance of consciousness later developed, and he thought to be caused by hepatic encephalopathy. Lactulose was admitted to our hospital on November 7, 1986. On and aminoleban were administrated, and the patient's admission, BP was 94/70 mmHg, body temperature was serum ammonia level decreased, but the disturbance of 37.4°C, and consciousness was confused. The patient's Generalized edema, pulmonary ascitesSpike and consciousness did not show anyeffusion, improvement. skin was dry; there wereWBC no other abnormal findings on Laboratory data showed 5800/mm3 (Band 3, Seg jaundice developed. Diuretics and frozen freshtoplasma fever continued and serum albumin decreased 0.9 g/dl. physical examination. 75, Ly 22) [4000-9000], RBC 412 X 10000/mm3 [414 were administered, but hypoalbuminemia, generalized 535], Hb ll.7[12.8-15.9]g/dl, Alb. 2.4[3.8-5.1]g/dl, edema, and pulmonary effusion failed to improve. On T-Bil. 2.6[0.1-1.0]mg/dl, D-Bil. 2.1[0.1-0.5]mg/dl, the 17th day after admission, gastrointestinal bleeding ZTT ll.3[4-12]KU, ALP 377[65-216]IU, LDH occured. He died of disseminated intravascular coagu 1820[216-383]IU, BUN 43[9-20]mg/dl, Cr. 1.6[0.8 lation (DIC) and pulmonary edema on the 29th day 1.2] mg/dl, BS 659[75-116] mg/dl, Fe 26[85-160] ^g/dl, after admission. From the Fourth Department of Internal Medicine, Toho University, School of Medicine, Tokyo and *the Department of Internal Medicine Sakura Hospital, Chiba Received for publication January 24, 1992; Accepted for publication June 23, 1992 Reprint requests should be addressed to Dr. Hiroshi Nemoto, the Fourth Department of Internal Medicine, Toho University Ohashi Hospit 2-17-6, Ohashi, Meguro-ku, Tokyo 153, Japan Intr oduction

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Nemotoet al revealed Y.E. serotype 03 antibody in histiocytes in the abscess. Moreover, serum Y.E. serotype 03 antibody was increased to X320 (normal level is below xlOO). Other pathological findings showed Aspergillosis in the lungs, heart, stomach, kidney and thyroid gland, but not in the liver. We could not detect Aspergillus by the culture of the sputum or urine, although it caused opportunistic infection due to severe infection, poorly controlled diabetes mellitus and hepatic encephalopathy. Discussion

Fig. 1. Postcontrast CT scan. Multiple round low density area disseminated throughout the liver parenchyma. Autopsy revealed multi focal liver abscesses (1-5 cm diameter) in bilateral liver lobes. Microscopic examin ation showed these abscesses to be composed of neutro cytes with fragmented nuclei, histiocytes with foam-like cell bodies and fibrinogen, but no bacterial mass, and hemosiderosis of the liver. Y.E. was not detectable in the abscess itself, though fluorescent antibody technique Table 1.

C a se

Y ear

H a ssig

1 94 9

B lo q u iau x M o llare t R a b so n K eet R a b so n R e in ic k e M a n tse R yan Im h o o f V ite ri F o th e rg il1 v a n L ier A lb e rti-F lo r B e e ch in g H e n rio n H opw o od L e ig h to n Ism a i1 C a u c h ie K ita y a m a O le se n W a tso n S in n o tt K hann a L eym an K am ed a P re se n t ca se

1968 1971 1972 1 9 74 1975 1977 1978 1979 1980 1981 1 9 82 1983 1984 1985 1986 1986 1987 19 8 7 19 8 7 19 8 8 19 8 9 19 8 9 19 8 9 19 8 9 19 8 9 19 9 1 19 9 2

Y.E., a gram negative rod-like organism, causes diarrhea, appendicitis, terminal ileitis and measenterial lymph-adenitis in children. Moreover it is associated with erythema nodosum, polyarthritis and Reiter's syndrome in adults case (1). Y.E. can grow at a low temperature, even when refrigerated at 5°C, and the infectious focus of Y.E. is thought to be fresh meats such and pork chopping (2). Itasischicken well known that and septicemia dueboards to Y.E. is rare in healthy adults. Leukemia, diabetes mellitus, liver cirrhosis, administration of immunosuppressive drugs and renal failure with peritoneal dialysis have been reported as a complication of sepsis (3).

Case Reports of Liver Abscesses Due to Yersinia A ge /S e x

60 m 40 f 69 m 57 m 75 m 55 m 59 m 64 m 3m m 48 m 71 m 46 m 38 m 57 m 72 m 74 m 71 f 71 f 65 m 47 m 37 f 38 m 59 m 62 f 37 m 65 m 56 m 37 m

C o m p lic a tio n H H H D H

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C M M C M S C ,L C O PD S S ,C R F C S C C ,D M

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Enterocolitica

L iv e r ab sce s s

C o u rse

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d e a th d e a th su rv iv al d e a th d e a th su rv iv al d e a th d e a th su rv iv al su rv iv al d e a th su rv iv al su rv iv al d e a th su rv iv al d e a th su rv iv al d e a th su rv iv al su rv iv al su rv iv al su rv iv a l su rv iv a l su rviv a l su rv iv a l su rv iv a l su rv iv a l d e a th d e a th

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05 09 05 03

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03

03 03

3m: 3-month, HC: hemochromatosis, HS: hemosiderosis, LC: liver cirrhosis, DM: diabetes mellitus, COPD: chronic obstructive pulmonary disease, CRF: chronic renal failure. 1126

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Liver Abscesses

A review of the literature revealed only twenty-nine reported cases of liver abscess caused by Y.E. throughout the world (males accounted for 24 cases, and females for 5) (4-30) (Table 1); in Japan there has only been two such reported cases (24, 30). The age range was 37-75 years old (average 57.1 ± 12.6 S.D.), with the exception of one 3-month old child (12). Y.E. infection in children is not rare, but liver abscesses caused by Y.E. has only been reported in one case. Twenty-three cases had Seven cases had reportedand CT five scancases of thehad liver, two cases multiple liver abscesses solitary abscess. revealed a solitary mass (17, 28) and five cases showed multiple small low density areas throughout the liver parenchyma (20, 22, 24, 29, 30). In the cases of multiple abscesses, they appear as multiple small sized areas like cysts and metastasis. Seventeen cases survived and twelve cases died. Most survival cases were after 1980's, which seems to be due to the advent of improved antibiotics (penicillins , cephalosporins , aminoglycosides , Liver abscess without tetracyclines, etc). septicemia was reported in eight cases, twenty-two cases were positive for Y.E. from liver abscesses, while eleven cases showed positive Y.E. in the liver and blood. The serotype of Y.E. was 03 in seven, 05 in two, 08 and 09 in one case each. Twenty-six cases were compromised hosts, twelve had hemochro matosis, seven had hemosiderosis, nine had diabetes mellitus, one had chronic obstructive lung disease and one had chronic renal failure. The present case had The severe infection caused the low level of serum Fe poorly-controlled diabetes mellitus and hemosiderosis. and TIBC, these data were no different when he was alive, it may concealed hemosiderosis by infection. Recently it has been reported that iron plays a signi ficant role in bacterial infection, and that overload of iron in a host can create conditions which facilitate bacterial infection. The route of iron overload in this case was unclear, as he had not received iron therapy or blood transfusions. The mechanism of liver abscess in most cases has been recognized to be the spread of an infection of the alimentary tract through the portal vein. In our case, the route of infection was not identified, but oral infection was implied because the initial symptom was diarrhea. References

Scavizzi M. Les septicemies humaines a (Yersinia enterocolitica) a propos de dix-sept cas recents. Presse Med 79: 345, 1972. 7) Rabson AR, Koornhof HJ, Notman J, Maxwell WG. Hepato splenic abscesses due to Yersinia enterocolitica. Br Med J 4: 341, 1972. 8) Keet EE, Yersinia enterocolitica septicemia. Source of infection and incubation period identified. NY State J Med 74: 2226, 1974. Rabson AR, Hallett AF, Koornhof HJ. Generalized Yersinia enterocolitica infection. J Inf Dis 131: 447, 1975. Reinicke V, Korner B. Fulminant septicemia caused by Yersinia enterocolitica. Scand J Infect Dis 9: 249, 1977. Mantse L, West J, Cosman HH, Mullens JE. Liver abscess due to Yersinia enterocolitica. Can Med Assoc J 199: 922, 12) Ryan ME, Burke PJ, Novinger QT, Shan NR. Hepatic abscesses due to Yersinia enterocolitica. Am J Dis Child 133: 961, 1979. 13) Imhoof B, Auckenthaler R. Septicemic a Yersinia enterocolitica. A propos d'un cas. Schweiz Med Wochensch 110: 1115, 1980 (Abstract in English). 14) Viteri AL, Howard PH, May JL, Ramesh GS, Roberts JW. Hepatic abscess due to Yersinia enterocolitica without bac teremia. Gastroenterol 81: 592, 1981. 15) Fothergill J, Mulira AEJL, Skirrow MB. Liver abscess due to an unusual strain of Yersinia enterocolitica. Postgrad Med J 58: 371, 1982. 16) Van Lier TAR, Lagaaij MB, Roos J. Een patient met lever abcessen door Yersinia enterocolitica-infetie. Ned Tijdschr Geneeskd 127: 293, 1983. 17) Alberti-Flor JJ, Jeffers LJ, Iskandarani M, Schiff ER. Successful medical management of a Yersinia enterocolitica liver abscess. Digestion 29: 250, 1984. 18) Beeching NJ, Hart HH, Synek BJ, Bremner DA. A patient with hemosiderosis and multiple liver abscesses due to Yersinia enterocolitica. Pothology 17: 530, 1985. 19) Henrion J, de Neve A, Heller F. Septicemie bacterienne: une complication meconnue de rhemochromatose idiopathique. etude de trois cas et revue de la litterature. Acta Clin Belg 41: 10, 1986 (Abstract in English). 20) Hopwood AH, Riddle BW. Yersinia enterocolitica hepatic abscesses. JK Med Assoc 84: 13, 1986. 21) Leighton PM, MacSween HM. Yersinia hepatic abscesses sub sequent to long-term iron therapy. JAMA 257: 964, 1987. 22) Ismail MHA, Hodkinson HJ, Patel M, Koornhof HJ. Multiple liver abscesses caused by Yersinia enterocolitica. A case report. S AfrMed J 72: 291, 1987. 23) Cauchie P, Vincken W, Peeter O, Charels K. Hemochromatosis and Yersinia enterocolitica septicemia. Dig Dis Sci 32: 1438, 1987. 24) KitayamaJ, OsadaT, Kobayashi R, et al. Acase report ofhepatic abscesses due to Yersinia enterocolitica associated with hemo siderosis. J Jpn Dig Surg 21: 2603, 1988. 25) Olesen LL, Ejlertsen T, Paulsen SM, Knudsen PR. Liver abscesses due to Yersinia enterocolitica in patients with hemochromatosis. J Int Med 225: 351, 1989. 26) Watson JA, Windsor JA, Wynne-Jones G. Conservative man agement of a Yersinia enterocolitica hepatic abscess. Aust N Z J 1) Une T. Studies on the pathogenicity of Yersinia enterocolitica.Surg I. 59: 353, 1989. Experimental infection in rabbits. Microbiol Immunol 21: 349, 27) Sinnott IV JT, Multhopp H, Lee J, Rechtine G. Yersinia entero 1977. colitica causing spinal osteomyelitis and empyema in a nonim 2) Lancet (ed). Yersinosis today. Lancet 1: 84, 1984. munocompromised host. South Med J 82: 399, 1989. 28) Khanna R, Levendoglu H. Liver abscess due to Yersinia en 3) Foberg U, Fryden A, Kihlstrom E, Persson K, Weiland O. Yersinia enterocolitica septicemia: Clinical and microbiological terocolitica: case report and review of the literature. Dig Dis Sci 34: 636, 1989. aspects. Scand J Infect Dis 18: 269, 1986. 4) Hassig A, Karrer J, Pusterla F. Ueber Psudotuberkulose beim 29) Leyman P, Baert AL, Marchal G, Fevery J. Ultrasound and CT Menschen. Schweiz Med Wochenschr 79: 971, 1949. of multi focal liver abscesses caused by Yersinia enterocolitica. 5) Bloquiaux W. Multiple Leverabscessen door Yersinia Entero JCAT 13: 913, 1989. 30) Kameda S, Kameyama T, Ooi S. A case of liver abscess caused colitica. Tijdschr Gastroenterol ll: 578, 1968 (Abstract in English). by Yersinia enterocolitica. J Jpn Gastroenterol 88: 991, 1991. 6) Mollaret H-H, Omland T, Henriksen SD, Baeroe PR, Rykner G, Internal

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