BRIEF COMMUNICATIONS
Septicemia caused by Yersinia enterocolitica S.L. NARASIMHAN,* MD; B.C. SCHIEVEN, BA, RT; E.W.R. CAMPSALL, MD, CM
Several age-related infectious syndromes have been ascribed to Yersinia enterocolitica. Acute gastroenteritis is the most common clinical form; more *than two thirds of such cases involve infants and young children.1 In older children and adolescents, abdominal pain simulating appendicitis or terminal ileitis is common and in adults abdominal pain and fever with or without arthritis or erythema nodosum are common features.2 Other clinical entities such as Reiter's disease, panophthalmitis and meningitis, abscesses, urinary tract infection, localized mucosal infections, hemolytic anemia, Pannaud's oculoglandular syndrome and synchronous-combined Meleney ulcer have been described in association with Y. enterocolitica infection.1-7 Septicemia due to this organism is rare and usually occurs in patients with underlying conditions such as diabetes, leukemia and cirrhosis, in those undergoing immunosuppressive therapy and in cases of alcohol abuse.'. We report a case of septicemia in an elderly woman who responded to gentamicin therapy.
Case report A 72-year-old woman was admitted to hospital because of fever, chills and malaise for 2 weeks. Diarrhea for 2 days at the onset of the illness had subsided spontaneously. She had had rheumatic fever at 16 years of age and mitral valvular disease for 20 years. Her temperature was 390C, jugular venous pressure was elevated, air entry was diminished and coarse rales were present over the base of the right lung. A grade 2/6 apical pansystolic murmur radiated to the left axilla. The liver was enlarged 7 cm below the costal margin From the department of clinical microbiology, Victoria Hospital, London *Present address: Department of medicine, General Hospital, St. John's, Nfld. Reprint requests to: Dr. E.W.R. Cam saIl, Department of clinical microbiology, Victoria Hospital, London, Ont. N6A 4G5
in the right midclavicular line and tenderness was present over the left hypochondrium. The leukocyte count was 10.8 X 109/L (70% polymorphonuclear cells, 16% bands, 12% lymphocytes and 2% monocytes). Urine sediment contained 25 to 30 erythrocytes per high-power field with occasional hyaline and granular casts. Chest roentgenography disclosed cardiac enlargement, pulmonary congestion and a small right pleural effusion. Five specimens of blood were taken for culture and gentamicin (80 mg q8h intravenously) was prescribed. All blood as well as stool cultures grew Y. enterocolitica (serotype 0:3, biotype 4, phage type 9) sensitive to gentamicin, cephalosporins, chloramphenicol and tetracycline, and resistant to ampicillin and kanamycin (confirmed by Dr. H.H. Mollaret of Institut Pasteur, Paris, France). The homologous antibody titre determined by tube agglutination was 1:1280. The patient was discharged taking digoxin and diuretics after 3 weeks of gentamicin therapy.
Discussion Fewer than 25 cases of septicemia due to Y. enterocolitica have been reported, chiefly as a complication in patients with an underlying disorder. Abramovitch and Butas'0 reported the first such case in Canada. Mollaret and colleagues1' stressed the severity of this condition and reported an overall mortality of 50%. Besides host resistance and age, the virulence of the organism may be important in determining the diversity of clinical features, morbidity and mortality in such infections. The source of the infection in our patient is not known although the gastrointestinal tract was the probable source, as suggested by the positive stool culture. Most clinical isolates of Y. enterocolitica in Canada are from feces of patients with acute gastroenteritis, and 0:3, as in our patient, is the predominant human serotype.'2 The recommended therapy for systemic infection with Y. enterocolitica is not yet established. There are reports
682 CMA JOURNAL/MARCH 18, 1978/VOL. 118
of poor response to a variety of antibiotics.2 Toma and Lafleur12 noted that none of the indole-negative serotype 0:3 strains were susceptible to ampicilun in vitro. Although Gutman, Wilfert and Quan13 reported uniform susceptibility to the combination of trimethoprim-sulfamethoxazole, Ericksson and Olc6n's14 patient was still septicemic after 60 hours of intravenous therapy with this combination in spite of in vitro susceptibility. Chloramphenicol therapy has lieen recommended in view of the similarity of Y. enterocolitica septicemia to systemic salmonellosis.2 Our patient responded well to gentamicin as evidenced by blood culture becoming sterile within 48 hours after initiation of antibiotic therapy. References 1. TOMA 5, DEIDRICK VR: Incidence of Yersinia enterocolitica and Y. pseudotuberculosis infections in Canada; 1975 semiannual report. Can Med Assoc .! 114: 16, 1976 2. RAasoN AR, HALLETr AF, KooSNHoF HJ: Generalized Yersinia enterocolitica infection. J Infect Dis 131: 447, 1975 3. SOLEM JH, LAssEN J: Reiter's disease following Yersinia enterocolitica infection. Scand I Infect Dis 3: 83, 1971 4. SONNENWIETH AC: Bacteremia with and without meningitis due to Yersinia entero-
colitica, Edwardsiella tarda, Comomonas terrigena, and Pseudomonas maltophilia. Ann NY Acad Sci 174: 488, 1970 5. KNORRING J VON, PETrEEssoN T: Haemolytic anaemia complicating Yersinia enterocolitica. infection. Report of a case. Scand I Haematol 9: 149, 1972 6. SONNENWIRTH AC, WEAVER RE: Yersinia enterocolitica. N Engi J Med 283: 1468, 1970 7. GREENSrEIN AJ, DREILING DA: Postoperative combined undermining infection of abdominal wound due to Yersinia enterocolitica. Mt
Sinai I Med NY 41: 665, 1974
8. JosEFssoN
K,
LINDBERG A:
Case report:
fatal Yersinia enterocolitica septicaemia. Scand I Infect Dis 7: 76, 1975
9. CHESSUM B, FRENGLEY JD, FLECK DG, et al:
Case of septicaemia due to Yersinia enterocolitica. Br Med J 3: 466, 1971 10. ABRAMOVITCH H, BUTAs CA: Septicemia due to Yersinia enterocolitica. Can Med Assoc .! 109: 1112, 1973 11. MOLLARET HH, OMLAND T, HENRIKEEN SD, et al: Les septic6mies humaines h "Yersinia enterocolitica". A propos de dix-sept cas r.cents. Presse Med 79: 345. 1971 12. TOMA 5, LAFLEUR L: Survey on the incidence of Yersinia enterocolitica infection in Canada. Appi Microbiol 28: 469, 1974 13. GUTMAN LT, WILFERT CM, QUAN T: Susceptibility of Yersinia enterocolitica to trimethoprim-sulfamethoxazole. I Infect Dis 128 (suppi): S538, 1973 14. ERIKssoN M, OLC.N P: Case report: septicaemia due to Yersinia enterocolitica in a non-compromised host. Scand I Infect Dis 7: 78, 1975
Septicemia caused by Yersinia enterocolitica S.L. NARASIMHAN,* MD; B.C. SCHIEVEN, BA, RT; E.W.R. CAMPSALL, MD, CM
Several age-related infectious syndromes have been ascribed to Yersinia enterocolitica. Acute gastroenteritis is the most common clinical form; more *than two thirds of such cases involve infants and young children.1 In older children and adolescents, abdominal pain simulating appendicitis or terminal ileitis is common and in adults abdominal pain and fever with or without arthritis or erythema nodosum are common features.2 Other clinical entities such as Reiter's disease, panophthalmitis and meningitis, abscesses, urinary tract infection, localized mucosal infections, hemolytic anemia, Pannaud's oculoglandular syndrome and synchronous-combined Meleney ulcer have been described in association with Y. enterocolitica infection.1-7 Septicemia due to this organism is rare and usually occurs in patients with underlying conditions such as diabetes, leukemia and cirrhosis, in those undergoing immunosuppressive therapy and in cases of alcohol abuse.'. We report a case of septicemia in an elderly woman who responded to gentamicin therapy.
Case report A 72-year-old woman was admitted to hospital because of fever, chills and malaise for 2 weeks. Diarrhea for 2 days at the onset of the illness had subsided spontaneously. She had had rheumatic fever at 16 years of age and mitral valvular disease for 20 years. Her temperature was 390C, jugular venous pressure was elevated, air entry was diminished and coarse rales were present over the base of the right lung. A grade 2/6 apical pansystolic murmur radiated to the left axilla. The liver was enlarged 7 cm below the costal margin From the department of clinical microbiology, Victoria Hospital, London *Present address: Department of medicine, General Hospital, St. John's, Nfld. Reprint requests to: Dr. E.W.R. Cam saIl, Department of clinical microbiology, Victoria Hospital, London, Ont. N6A 4G5
in the right midclavicular line and tenderness was present over the left hypochondrium. The leukocyte count was 10.8 X 109/L (70% polymorphonuclear cells, 16% bands, 12% lymphocytes and 2% monocytes). Urine sediment contained 25 to 30 erythrocytes per high-power field with occasional hyaline and granular casts. Chest roentgenography disclosed cardiac enlargement, pulmonary congestion and a small right pleural effusion. Five specimens of blood were taken for culture and gentamicin (80 mg q8h intravenously) was prescribed. All blood as well as stool cultures grew Y. enterocolitica (serotype 0:3, biotype 4, phage type 9) sensitive to gentamicin, cephalosporins, chloramphenicol and tetracycline, and resistant to ampicillin and kanamycin (confirmed by Dr. H.H. Mollaret of Institut Pasteur, Paris, France). The homologous antibody titre determined by tube agglutination was 1:1280. The patient was discharged taking digoxin and diuretics after 3 weeks of gentamicin therapy.
Discussion Fewer than 25 cases of septicemia due to Y. enterocolitica have been reported, chiefly as a complication in patients with an underlying disorder. Abramovitch and Butas'0 reported the first such case in Canada. Mollaret and colleagues1' stressed the severity of this condition and reported an overall mortality of 50%. Besides host resistance and age, the virulence of the organism may be important in determining the diversity of clinical features, morbidity and mortality in such infections. The source of the infection in our patient is not known although the gastrointestinal tract was the probable source, as suggested by the positive stool culture. Most clinical isolates of Y. enterocolitica in Canada are from feces of patients with acute gastroenteritis, and 0:3, as in our patient, is the predominant human serotype.'2 The recommended therapy for systemic infection with Y. enterocolitica is not yet established. There are reports
682 CMA JOURNAL/MARCH 18, 1978/VOL. 118
of poor response to a variety of antibiotics.2 Toma and Lafleur12 noted that none of the indole-negative serotype 0:3 strains were susceptible to ampicilun in vitro. Although Gutman, Wilfert and Quan13 reported uniform susceptibility to the combination of trimethoprim-sulfamethoxazole, Ericksson and Olc6n's14 patient was still septicemic after 60 hours of intravenous therapy with this combination in spite of in vitro susceptibility. Chloramphenicol therapy has lieen recommended in view of the similarity of Y. enterocolitica septicemia to systemic salmonellosis.2 Our patient responded well to gentamicin as evidenced by blood culture becoming sterile within 48 hours after initiation of antibiotic therapy. References 1. TOMA 5, DEIDRICK VR: Incidence of Yersinia enterocolitica and Y. pseudotuberculosis infections in Canada; 1975 semiannual report. Can Med Assoc .! 114: 16, 1976 2. RAasoN AR, HALLETr AF, KooSNHoF HJ: Generalized Yersinia enterocolitica infection. J Infect Dis 131: 447, 1975 3. SOLEM JH, LAssEN J: Reiter's disease following Yersinia enterocolitica infection. Scand I Infect Dis 3: 83, 1971 4. SONNENWIETH AC: Bacteremia with and without meningitis due to Yersinia entero-
colitica, Edwardsiella tarda, Comomonas terrigena, and Pseudomonas maltophilia. Ann NY Acad Sci 174: 488, 1970 5. KNORRING J VON, PETrEEssoN T: Haemolytic anaemia complicating Yersinia enterocolitica. infection. Report of a case. Scand I Haematol 9: 149, 1972 6. SONNENWIRTH AC, WEAVER RE: Yersinia enterocolitica. N Engi J Med 283: 1468, 1970 7. GREENSrEIN AJ, DREILING DA: Postoperative combined undermining infection of abdominal wound due to Yersinia enterocolitica. Mt
Sinai I Med NY 41: 665, 1974
8. JosEFssoN
K,
LINDBERG A:
Case report:
fatal Yersinia enterocolitica septicaemia. Scand I Infect Dis 7: 76, 1975
9. CHESSUM B, FRENGLEY JD, FLECK DG, et al:
Case of septicaemia due to Yersinia enterocolitica. Br Med J 3: 466, 1971 10. ABRAMOVITCH H, BUTAs CA: Septicemia due to Yersinia enterocolitica. Can Med Assoc .! 109: 1112, 1973 11. MOLLARET HH, OMLAND T, HENRIKEEN SD, et al: Les septic6mies humaines h "Yersinia enterocolitica". A propos de dix-sept cas r.cents. Presse Med 79: 345. 1971 12. TOMA 5, LAFLEUR L: Survey on the incidence of Yersinia enterocolitica infection in Canada. Appi Microbiol 28: 469, 1974 13. GUTMAN LT, WILFERT CM, QUAN T: Susceptibility of Yersinia enterocolitica to trimethoprim-sulfamethoxazole. I Infect Dis 128 (suppi): S538, 1973 14. ERIKssoN M, OLC.N P: Case report: septicaemia due to Yersinia enterocolitica in a non-compromised host. Scand I Infect Dis 7: 78, 1975
