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Autopsy Findings
References
Postmortem examination disclosed gross and histologic evidence of burn-wound infection and severe necrotizing bronchopneumonia. Septicemia could have arisen from either site of infection. Salient to this report was the histologic finding of a profuse growth of hyphae within the superficial necrotic debris in a postmortem skin specimen from the left thigh. None were seen in several skin specimens obtained elsewhere. These hyphae were septate and dichotomously branched at approximately 45 degrees. Morphologically this suggested Aspergillus. Extending outward from the superficial fungal growth were septate hyphae bearing conidiophores (Fig. 1). The morphology is diagnostic of Aspergillus spp., probably Aspergillus fumigatus. 10.
The burned patient has long been known to be susceptible to saprophytic fungal growth. I _ 3 H _ 1 1 1 3 1 5 1 6 Though Candida are the fungi most frequently recovered from burn wounds, Aspergillus spp. and the Phycomycetes group more commonly invade tissue, leading to serious morbidity and mortality. 10 There are several reports of Aspergillus spp. causing burn-wound infection, 2 - 3(i1015 but none mention the conidiophores characteristic of Aspergillus. "Fruiting bodies" developing in brOnchiectatic lungs and lung cavities from diverse causes all have in common exposure to air. It might well be anticipated that altered tissue such as the burn wound with its exposure to the atmosphere will occasionally permit growth of Aspergillus conidiophores.
12.
13.
14. 15.
16.
Yersinia enterocolitica Septicemia LINDA M. (KANTOR) CAPLAN, M.S., M (ASCP), MARGARET L DOBSON, M.D., AND HENRY DORKIN, M.D.
Caplan, Linda M. (Kantor), Dobsoh, Margaret L., and Dorkin, Henry: Yersinia enterocolitica septicemia. Am J Clin Pathol 69: 189-192, 1978. Yersinia enterocolitica was recovered from the blood of an infant with sepsis and fever but with few gastrointestinal symptoms. The age of this patient was unusual as septicemia owing to this organism has most frequently been
Received December 2, 1976; received revised manuscript February 2, 1977; accepted for publication February 2, 1977. Address reprint requests to Ms. Caplan: Clinical Microbiology Laboratory, Room 2309, Children's Hospital National Medical Center, 111 Michigan Ave., N.W., Washington, D.C. 20010.
The Division of Microbiology, Department of Laboratory Medicine, and the Department of Pediatrics, The Johns Hopkins Medical Institutions, Baltimore, Maryland
seen in adults. Because of the absence of digestive symptoms, it is uncertain what the portal of entry of the organism might have been. Yersinia enterocolitica is not often recognized, either because of difficulties in identification or because it may not be recognized as a human pathogen. (Key words: Yersinia enterocolitica; Enterobacteriaceae; Septicemia.)
0002-9173-78-0200—0189S00.60 © American Society of Clinical Pathologists
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Discussion
Abramowsky CR, Quinn D, Bradford WD, et al: Systemic infection by Fusarium in a burned child. The emergence of a saprophytic strain. J Pediatr 84:561-564, 1974 Bruck HM, Nash G, Foley FD, et al: Opportunistic fungal infection of the burn wound with Phycomycetes and Aspergillus. A clinical-pathologic review. Arch Surg 102:476-482. 1971 Bruck HM, Nash G, Stein JM. et al: Studies on the occurrence and significance of yeasts and fungi in the burn wound. Ann Surg 176:108-110. 1972 Civilia ES, Tost J F . Jimenez AL, et al: Root-like hyphal structures in aspergillar otomycosis. Arq Inst Biol S Paulo 39:137-139, 1972 Emmons CW, Binford CH, UtzTP: Medical Mycology. Second edition. Philadelphia, Lea and Febiger, 1970, p 264 Foley FD: The burn autopsy. Fatal complications of burns. Am J Clin Pathol 52:1-13; 1969 Foley FD, Shuck JM: Brun-wound infection with phycomycetes requiring amputation of hand. JAMA 203:596, 1968 Law EJ, Kim OJ, Stieritz DD, et al: Experience with systemic candidiasis in the burned patient. J Trauma 12:543-552, 1972 MacMillan BG, Law EJ, Holder IA: Experience with Candida infections in the burn patient. Arch Surg 104:509-514. 1972 Nash G, Foley FD, Goodwin NM Jr. et al: Fungal burn wound infection. JAMA 215:1664-1666, 1971 Nash G, Foley FD, Pruitt BA Jr: "Candida" burn-wound invasion. A cause of systemic candidiasis. Arch Pathol 90:75-78, 1970 Nime FA, Hutchins GM: Oxalosis caused by Aspergillus infections. Johns Hopkins Med J 133:183-194, 1973 Rabin ER, Lundberg GD, Mitchell ET: Mucormycosis in severely burned patients. Report of two cases with extensive destruction of the face and nasal cavity. N Eng J Med 264:1286-1289, 1961 Rosenheim SH, Schwarz J: Cavitary pulmonary cryptococcosis complicated by aspergilloma. Am Rev Resp Dis 111:549-553. 1975 Salisbury RE, Silverstein P, Goodwin NM Jr: Upper extremity fungal invasions secondary to large burns. Plast Reconstr Surg 54:654-659, 1974 Stieretz DD, Law EJ, Holder IA: Speciation and amphotericin B sensitivity studies on blood isolates of Candida from burned patients. J Clin Pathol 26:405-408, 1973
A.J.C.P. . February 1978
CAPLAN, DOBSON AND DORKIN
190
Table I. Characteristics of Yersinia enterocolitica Isolate Test
Result
LIA Decarboxylase ornithine Arginine Lysine Hydrogen sulfide Indole* Motility 25 C 37 C Citrate Urease DNase
Alkaline/acid +
+
+
-
Test
Result
Oxidase Acid from Arabinose Sorbitol Mannitol Adonitol Inositol Raffinose Rhamnose Phenylalanine deaminase TSI
+ + +
-
later identified as Yersinia enterocolitica, was recovered from the admission blood culture. Additional cultures, including blood, urine, spinal fluid, throat, nasopharynx, and stool, did not yield Yersinia enterocolitica. A presumptive diagnosis of septicemia was made on admission and treatment with methicillin, 300 mg/kg, ampicillin 300 mg/kg, and gentamicin, 6 mg/kg, was begun. Following recovery of the organism from the blood and determination of in-vitro antibiotic susceptibilities, treatment was continued with gentamicin alone for 10 days. The patient was discharged, asymptomatic, 13 days after admission. At the age of 6 months the patient was brought to the outpatient department with a nonspecific body rash and no other symptom. A stool culture obtained at that time was positive for Salmonella infantis. Hospitalization was not necessary, and the rash cleared spontaneously without specific treatment. A repeat stool culture three weeks later was negative for the Salmonella organism.
-
Acid/acid No gas
* Positive by (he spot-test method.
Report of a Case A 5-week-old black female infant was seen in the Johns Hopkins Hospital emergency room with fever. She had been born to a 17-year-old primigravida mother after a pregnancy complicated only by one vaginal infection and occasional spotting. At birth the infant's weight had been 4,460 g; length, 53 cm; head circumference, 38.5 cm. The child had been discharged from the hospital four days after birth. She was kept at home and fed 6 - 8 ounces of Similac with iron every 3-4 hours, and occasionally given water and cereal. She had been well until one day prior to admission, when she had vomited once and had been felt to be slightly warm. On the day of admission she was febrile, with a temperature of 102 F (38.7 C), and vomited twice, but had no diarrhea. She had slight rhinorrhea, ate well, but was somewhat lethargic. An initial evaluation did not reveal the source of the fever. On admission, the child was found to be somewhat irritable, but in no acute distress. Vital signs included a temperature of 38.7 C, pulse 160/min and respiratory rate 50-80/min. Physical examination was remarkable only for a perineal rash and a small area of moist chafing under the chin. A chest film was negative. The clinical laboratory findings included a hematocrit of 30% and a leukocyte count of 16,100, with 40% neutrophils, 18% band forms, 28% lymphocytes, 13% monocytes, and 1% eosinophils. Blood glucose was 129 mg/dl. Serum electrolytes and cerebrospinal fluid values were within normal limits. Urinalysis revealed 1 - 4 leukocytes per high-power field. A non-lactose-fermenting, gram-negative rod,
The Yersinia enterocolitica organism was identified by examination of microscopic and colonial morphology and on the basis of biochemical testing. Gramstained smears of the positive blood culture and of colonies growing on MacConkey agar (BBL) and on trypticase soy agar with 5% sheep blood (BBL) revealed gram-negative coccobacilli. The organism produced small, colorless colonies on MacConkey agar; on 5% sheep blood agar the colonies were 1 to 2 mm in diameter, circular, grayish-white and smooth in consistency. The results of the biochemical testing are listed in Table 1. As shown in the table, the organism produced an alkaline slant and acid butt on lysine-iron agar (LIA), indicative of inability to deaminate or decarboxylate lysine. The organism was able to decarboxylate ornithine but not arginine. Hydrogen sulfide was not produced, and the spot test for indole production was positive. Motility was negative at 37 C and positive at room temperature. The urease test was positive, but tests for DNase, oxidase, and phenylalanine deaminase and growth on citrate were negative. The organism fermented arabinose, sorbitol and mannitol, but not adonitol, inositol, raffinose and rhamnose. An acid slant and acid butt with no gas was produced in the TSI medium, which was evidence of sucrose, not lactose, fermentation. Confirmation of the identification of the bacterial isolate described here was performed by the Maryland State Department of Health. Antibiotic susceptibility testing was performed by an agar dilution method currently in use in the Microbiology Laboratory, The Johns Hopkins Hospital.6 Media were prepared by adding antibiotics to cooled, molten Mueller-Hinton agar (BBL) and dispensing into 10 x 10-cm square petri plates, approximately 35 ml per plate. The bacterial isolate selected for antibiotic susceptibility testing was inoculated into 2 ml
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THIS REPORT describes the isolation of Yersinia enterocolitica from the blood of a 5-week-old infant with sepsis. This organism, which culturally and biochemically may resemble other Enterobacteriaqeae, can cause a variety of infections in man. It has been reported to occur in association with mesenteric lymphadenitis, gastroenteritis, and arthritis in children, and septicemia, fever of unknown origin, arthralgia, and erythema nodosum in adults.'0 It appears that the association with acute gastroenteritis occurs most commonly in young children.101318 This case is of special interest since it involves an infant with septicemia and fever, but with little gastrointestinal involvement.
Bacteriology
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CASE REPORTS
Vol. 69 • No. 2
of Mueller-Hinton broth (BBL), incubated for 2 hours in a 37 C water bath, and then adjusted with saline solution to the turbidity of a 0.5 McFarland standard, representing approximately 108 organisms per ml. Using a Steers replicating device, 22 which can be used to inoculate 36 isolates simultaneously onto a single plate of medium, 0.01 ml of a 1:10 dilution of the standardized suspension of organism was spotted onto the surface of the medium, with the final inoculum size being 10' organisms. The diluted bacterial suspension was subcultured onto trypticase soy agar with 5% sheep blood and incubated at 37 C for 18 hours to confirm purity of the culture.
Discussion Yersinia enterocolitica was first recognized in the United States in 1933 and was first reported in 1939.421 In the years 1947 to 1966, no case of human infection with this organism was recognized in the United States, and between 1966 and 1972, only 29 culture-proven Yersinia enterocolitica infections are known to have occurred. 212(i In Europe, however, 1,000 cases pf infection with this microorganism were diagnosed between 1964 and 1971.,4-21 Yersiniosis in Finland has frequently been described, 2 ' 0 2 3 and reports of infections have come from Denmark, 23 England, 8 and Sweden. 15 Outside of Europe, Yersinia infections have been reported from South Africa16 and Australia." In one discussion of the geographical distribution of Yersinia enterocolitica, it was noted that the organism was found predominantly in Western Europe, especially in Sweden, Belgium, France, Denmark, Finland and Switzerland, and also in Central Europe, in Czechoslovakia, Rumania, and the U.S.S.R. 16 Only sporadic cases were observed in the United States. Recently, however, 24 human isolates of Yersinia enterocolitica submitted to the California Department of Health from 1968 to 1975 were described. 3 A survey of the incidence of Yersinia enterocolitica infection in Canada revealed 256 human and 22 non-human isolates. 24 It is interesting that the common serotypes of
Concentrations Tested (^g/ml) Tetracycline Chloramphenicol Cephalothin Ampicillin Gentamicin Kanamycin Amikacin
1, 2, 4, 16 2, 4, 8 2, 8, 32 1, 2, 4, 16 1, 2, 4, 8 2, 4, 8, 16 2, 4, 8, 16
MIC (/xg/ml) 2 4 32 16 I 4 2
Yersinia enterocolitica repeatedly isolated in Europe and Canada are serotypes 3 and 9, while serotype 8 is seen most commonly in the United States. 3 In the cases isolated from South Africa, serotype 3 was reported. 17 These findings may suggest that there are differences in the epidemiologies of Yersinia enterocolitica infections in the United States and other countries. The apparent low incidence of isolation of Yersinia enterocolitica in the United States may be due to three factors: (1) it may not actually have the same geographic distribution in the United States that it has in other countries; (2) it may not be recognized by current identification procedures used in many laboratories; (3) it may be recognized but not reported or sent for confirmation to state laboratories or to the Center for Disease Control. This lack of recognition of infections caused by Yersinia enterocolitica may, in turn, be attributed to (1) the difficulty in the isolation and differentiation from other members of the family Enterobacteriaceae, and (2) the lack of awareness of the association of Yersinia with disease other than mesenteric lymphadenitis. Yersinia enterocolitica may be isolated from a variety of clinical sources, including blood, cerebrospinal fluid, urine, eye, stool, throat, trachea, and wound specimens. 4 2 0 A hepatosplenic abscess due to Yersinia enterocolitica has been described, 17 and the organism has also been cultured from enteric contents of patients with symptoms suggesting acute appendicitis. 15 Septicemia due to Yersinia enterocolitica has been described infrequently, but four cases were reported during the period 1971-1975. 15 - 712 All of these occurred in patients more than 65 years old. In all four cases, the patients were febrile but did not have gastrointestinal involvement. In addition, although it has generally been accepted that most cases of septicemia due to Yersinia enterocolitica are associated with an underlying disease, all of these cases occurred in patients with no recognized underlying illness. The infant described in this report was not known to have any underlying disease. It is uncertain whether there was any relationship between the Salmonella infantis subsequently isolated
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The seven antibiotics tested were tetracycline, chloramphenicol, cephalothin, ampicillin, gentamicin, kanamycin, and amikacin. Results were expressed as the minimum inhibitory concentration of the antibiotic tested in micrograms per milliliter. The concentrations of the antibiotics tested and the antibiotic susceptibility pattern of the Yersinia enterocolitica isolate described here are shown in Table 2. The organism appeared to be moderately resistant to ampicillin and cephalothin and sensitive to tetracycline, chloramphenicol, gentamicin, kanamycin and amikacin.
Table 2. Antibiotic Susceptibility of Yersinia enterocolitica Isolate
192
from this patient's stool and the previous infection with Yersinia enterocolitica. Concurrent infections with Yersinia enterocolitica and other enteric pathogens have been described. 161819 One report recorded an infection with Yersinia enterocolitica in an infant with enteritis who also had enteropathogenic Escherichia coli isolated from his stools.1!) Another report described two patients with gastroenteritis, both of whom had Yersinia enterocolitica isolated from their stools concurrently with Salmonella montevideo and an enteropathogenic Escherichia coli, respectively. 16 Additional enteric pathogens, two Salmonella organisms and one Shigella, were reported to be isolated from three patients with Yersinia enterocolitica infection.18
Dr. Patricia Charache reviewed the manuscript.
References 1. Abramovitch H, Butas C: Septicemia due to Yersinia enterocolitica. Can Med Assoc J 109:1112, 1973 2. Ahvonen P: Human yersiniosis in Finland. 1. Bacteriology and serology. Ann Clin Res 4:30-38, 1972 3. Bissett ML: Yersinia enterocolitica isolates from humans in California, 1968-1975. J Clin Microbiol 4:137-144. 1976 4. Bottone EJ, Chester B, Malowany MS, et al: Unusual Yersinia enterocolitica isolates not associated with mesenteric lymphadenitis. Appl Microbiol 27:858-861, 1974 5. ChessumB, FrengleyJD, Fleck DG,etal: Case of septicemia due to Yersinia enterocolitica. Br Med J 3:466, 1971 6. Ericcson HM, Sherris JC: Antibiotic sensitivity testing. Report of an international collaborative study. Acta Pathol Microbiol, Sect B, suppl 217. Copenhagen, Munksgaard, 1971 7. Eriksson M, Olcen P: Septicemia due to Yersinia enterocolitica in a non-compromised host. Scand J Infect Dis 7:78-80. 1975 8. Gurry JF: Acute terminal ileitis and Yersinia infection. Br Med J 2:264-265, 1974 9. Gutman LT, Ottesen EA. Quan TJ, et al: An inter-familial outbreak of Yersinia enterocolitica enteritis. N Engl J Med 288:1372-1376, 1973 10. Hallstrom K, Sairanen E, Ohela K: A pilot clinical study on yersinioses in south-eastern Finland. Acta Med Scand 191:485-491, 1972 11. Hewstone AS, Davidson GP: Yersinia enterocolitica septicemia with arthritis in a thalassemic child. Med J Aust 1:1035-1038. 1972 12. Josefson K, Lindberg A: Fatal Yersinia enterocolitica septicemia. Scand J Infect Dis 7:76-77, 1975 13. Kohl S, Jacobson JA, Nahmias A: Yersinia enterocolitica infections in children. J Pediatr 89:77-79, 1976 14. Mollaret HH: Human Yersinia enterocolitica infections in 1970. Report of 642 recent cases. Clinical and epidemiological aspects. Pathol Biol 19:189-205, 1970 15. Nilehn B: Studies on Yersinia enterocolitica. Acta Pathol Microbiol Scand 69:83-91, 1967 16. Rabson AR, Koornhof HJ: Yersinia enterocolitica infections in South Africa. South Afr Med J 46:798-803, 1972 17. Rabson AR, Koornhof, HJ, Notmen J, et al: Hepatosplenic abscesses due to Yersinia enterocolitica. Br Med J 4:341, 1972 18. Randall C, Bannatyne RM: Experience with Yersinia enterocolitica at the hospital for sick children. 1972-74. Can Med Assoc J 113:542-543, 1975 19. Shieven BC, Randall C: Enteritis due to Yersinia enterocolitica. J Pediatr 84:402-404, 1974 20. Sonnenwirth A: Bacteremia with and without meningitis due to Yersinia enterocolitica. Edwardsiella tarda. Coinamonas terrigena, and Pseudomonas nuiltophilia. Ann NY Acad Sci 174:488-494, 1970 21. Sonnenwirth AC: Yersinia. Manual of Clinical Microbiology. Second edition. Edited by Lennette EH, Spaulding EH, Truant JP. American Society for Microbiology, Washington, D.C., 1974, pp 226-229 22. Steers E, Foltz EL, Graves BS, et al: An inocula replicating apparatus for routine testing of bacterial susceptibility to antibiotics. Antibiot Chemother 9:307, 1959 23. ToivanenP, OlkkanenL,Toivanen A,et al: Hospital outbreak of Yersinia enterocolitica infection. Lancet 1:801-803, 1973 24. Toma S, Lafleur L: Survey on the incidence of Yersinia enterocolitica infection in Canada. Appl Microb 28:469-473, 1974 25. von Knorring J, Pettersson T: Haemolytic anemia complicating Yersinia enterocolitica infection. Scand J Haematol 9:149152, 1972 26. Weaver RE, Jordan JG: Recent human isolates of Yersinia enterocolitica, Contributions to Microbiology and Immunology. Vol. 2. Edited by Winblad S. Basel, S. Karger, 1973, pp 120-125
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The presence of Yersinia enterocolitica in many animal species suggests that the disease is a zoonosis. 16 It has been recovered from a large variety of animal species, including chinchillas, hares, monkeys, antelopes, horses, dogs and pigs.8-24 A pet dog present in the household occupied by the infant described here was not tested for carrier state. Some investigators consider the dog to be the most likely source of infection for man, while others consider the pig to be the main source of human infection. 914 Only the pig has regularly been found to carry one of the same serologic groups as that found in man (serotype 3), and the organism has been recovered from the stools and mesenteric lymph nodes of apparently healthy pigs. In addition, the geographic distribution of porcine strains of Yersinia enterocolitica, as shown by phage typing, corresponds to that found for man. 16 However, in spite of this evidence, there is still no definite proof of a connection between human and animal illness. Also, because of the finding of symptomless carriers, man himself may prove to be an important reservoir of Yersinia enterocolitica.I6 The portal of entry of Yersinia enterocolitica appears to be the digestive tract. This corresponds well with the frequency of digestive symptoms, the high incidence of lesions in the ileum, appendix and mesenteric lymph nodes and the seasonal incidence, which tends to follow that of other gastrointestinal diseases. 16 The case reported here, however, occurred in a patient with little gastrointestinal involvement and none of the lesions mentioned above. It is, therefore, uncertain what the portal of entry might have been. Suggested possibilities for transmission of Yersinia enterocolitica include: (1) ingestion of contaminated food; (2) contact with an infected animal such as a pet; (3) person-to-person transmission through hand-tomouth contact in an infected family.9 Acknowledgment.
A.J.C.P. • February 1978
CAPLAN, DOBSON AND DORKIN
CASE REPORTS
Vol. 69 • No. 2
Autopsy Findings
References
Postmortem examination disclosed gross and histologic evidence of burn-wound infection and severe necrotizing bronchopneumonia. Septicemia could have arisen from either site of infection. Salient to this report was the histologic finding of a profuse growth of hyphae within the superficial necrotic debris in a postmortem skin specimen from the left thigh. None were seen in several skin specimens obtained elsewhere. These hyphae were septate and dichotomously branched at approximately 45 degrees. Morphologically this suggested Aspergillus. Extending outward from the superficial fungal growth were septate hyphae bearing conidiophores (Fig. 1). The morphology is diagnostic of Aspergillus spp., probably Aspergillus fumigatus. 10.
The burned patient has long been known to be susceptible to saprophytic fungal growth. I _ 3 H _ 1 1 1 3 1 5 1 6 Though Candida are the fungi most frequently recovered from burn wounds, Aspergillus spp. and the Phycomycetes group more commonly invade tissue, leading to serious morbidity and mortality. 10 There are several reports of Aspergillus spp. causing burn-wound infection, 2 - 3(i1015 but none mention the conidiophores characteristic of Aspergillus. "Fruiting bodies" developing in brOnchiectatic lungs and lung cavities from diverse causes all have in common exposure to air. It might well be anticipated that altered tissue such as the burn wound with its exposure to the atmosphere will occasionally permit growth of Aspergillus conidiophores.
12.
13.
14. 15.
16.
Yersinia enterocolitica Septicemia LINDA M. (KANTOR) CAPLAN, M.S., M (ASCP), MARGARET L DOBSON, M.D., AND HENRY DORKIN, M.D.
Caplan, Linda M. (Kantor), Dobsoh, Margaret L., and Dorkin, Henry: Yersinia enterocolitica septicemia. Am J Clin Pathol 69: 189-192, 1978. Yersinia enterocolitica was recovered from the blood of an infant with sepsis and fever but with few gastrointestinal symptoms. The age of this patient was unusual as septicemia owing to this organism has most frequently been
Received December 2, 1976; received revised manuscript February 2, 1977; accepted for publication February 2, 1977. Address reprint requests to Ms. Caplan: Clinical Microbiology Laboratory, Room 2309, Children's Hospital National Medical Center, 111 Michigan Ave., N.W., Washington, D.C. 20010.
The Division of Microbiology, Department of Laboratory Medicine, and the Department of Pediatrics, The Johns Hopkins Medical Institutions, Baltimore, Maryland
seen in adults. Because of the absence of digestive symptoms, it is uncertain what the portal of entry of the organism might have been. Yersinia enterocolitica is not often recognized, either because of difficulties in identification or because it may not be recognized as a human pathogen. (Key words: Yersinia enterocolitica; Enterobacteriaceae; Septicemia.)
0002-9173-78-0200—0189S00.60 © American Society of Clinical Pathologists
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Discussion
Abramowsky CR, Quinn D, Bradford WD, et al: Systemic infection by Fusarium in a burned child. The emergence of a saprophytic strain. J Pediatr 84:561-564, 1974 Bruck HM, Nash G, Foley FD, et al: Opportunistic fungal infection of the burn wound with Phycomycetes and Aspergillus. A clinical-pathologic review. Arch Surg 102:476-482. 1971 Bruck HM, Nash G, Stein JM. et al: Studies on the occurrence and significance of yeasts and fungi in the burn wound. Ann Surg 176:108-110. 1972 Civilia ES, Tost J F . Jimenez AL, et al: Root-like hyphal structures in aspergillar otomycosis. Arq Inst Biol S Paulo 39:137-139, 1972 Emmons CW, Binford CH, UtzTP: Medical Mycology. Second edition. Philadelphia, Lea and Febiger, 1970, p 264 Foley FD: The burn autopsy. Fatal complications of burns. Am J Clin Pathol 52:1-13; 1969 Foley FD, Shuck JM: Brun-wound infection with phycomycetes requiring amputation of hand. JAMA 203:596, 1968 Law EJ, Kim OJ, Stieritz DD, et al: Experience with systemic candidiasis in the burned patient. J Trauma 12:543-552, 1972 MacMillan BG, Law EJ, Holder IA: Experience with Candida infections in the burn patient. Arch Surg 104:509-514. 1972 Nash G, Foley FD, Goodwin NM Jr. et al: Fungal burn wound infection. JAMA 215:1664-1666, 1971 Nash G, Foley FD, Pruitt BA Jr: "Candida" burn-wound invasion. A cause of systemic candidiasis. Arch Pathol 90:75-78, 1970 Nime FA, Hutchins GM: Oxalosis caused by Aspergillus infections. Johns Hopkins Med J 133:183-194, 1973 Rabin ER, Lundberg GD, Mitchell ET: Mucormycosis in severely burned patients. Report of two cases with extensive destruction of the face and nasal cavity. N Eng J Med 264:1286-1289, 1961 Rosenheim SH, Schwarz J: Cavitary pulmonary cryptococcosis complicated by aspergilloma. Am Rev Resp Dis 111:549-553. 1975 Salisbury RE, Silverstein P, Goodwin NM Jr: Upper extremity fungal invasions secondary to large burns. Plast Reconstr Surg 54:654-659, 1974 Stieretz DD, Law EJ, Holder IA: Speciation and amphotericin B sensitivity studies on blood isolates of Candida from burned patients. J Clin Pathol 26:405-408, 1973
A.J.C.P. . February 1978
CAPLAN, DOBSON AND DORKIN
190
Table I. Characteristics of Yersinia enterocolitica Isolate Test
Result
LIA Decarboxylase ornithine Arginine Lysine Hydrogen sulfide Indole* Motility 25 C 37 C Citrate Urease DNase
Alkaline/acid +
+
+
-
Test
Result
Oxidase Acid from Arabinose Sorbitol Mannitol Adonitol Inositol Raffinose Rhamnose Phenylalanine deaminase TSI
+ + +
-
later identified as Yersinia enterocolitica, was recovered from the admission blood culture. Additional cultures, including blood, urine, spinal fluid, throat, nasopharynx, and stool, did not yield Yersinia enterocolitica. A presumptive diagnosis of septicemia was made on admission and treatment with methicillin, 300 mg/kg, ampicillin 300 mg/kg, and gentamicin, 6 mg/kg, was begun. Following recovery of the organism from the blood and determination of in-vitro antibiotic susceptibilities, treatment was continued with gentamicin alone for 10 days. The patient was discharged, asymptomatic, 13 days after admission. At the age of 6 months the patient was brought to the outpatient department with a nonspecific body rash and no other symptom. A stool culture obtained at that time was positive for Salmonella infantis. Hospitalization was not necessary, and the rash cleared spontaneously without specific treatment. A repeat stool culture three weeks later was negative for the Salmonella organism.
-
Acid/acid No gas
* Positive by (he spot-test method.
Report of a Case A 5-week-old black female infant was seen in the Johns Hopkins Hospital emergency room with fever. She had been born to a 17-year-old primigravida mother after a pregnancy complicated only by one vaginal infection and occasional spotting. At birth the infant's weight had been 4,460 g; length, 53 cm; head circumference, 38.5 cm. The child had been discharged from the hospital four days after birth. She was kept at home and fed 6 - 8 ounces of Similac with iron every 3-4 hours, and occasionally given water and cereal. She had been well until one day prior to admission, when she had vomited once and had been felt to be slightly warm. On the day of admission she was febrile, with a temperature of 102 F (38.7 C), and vomited twice, but had no diarrhea. She had slight rhinorrhea, ate well, but was somewhat lethargic. An initial evaluation did not reveal the source of the fever. On admission, the child was found to be somewhat irritable, but in no acute distress. Vital signs included a temperature of 38.7 C, pulse 160/min and respiratory rate 50-80/min. Physical examination was remarkable only for a perineal rash and a small area of moist chafing under the chin. A chest film was negative. The clinical laboratory findings included a hematocrit of 30% and a leukocyte count of 16,100, with 40% neutrophils, 18% band forms, 28% lymphocytes, 13% monocytes, and 1% eosinophils. Blood glucose was 129 mg/dl. Serum electrolytes and cerebrospinal fluid values were within normal limits. Urinalysis revealed 1 - 4 leukocytes per high-power field. A non-lactose-fermenting, gram-negative rod,
The Yersinia enterocolitica organism was identified by examination of microscopic and colonial morphology and on the basis of biochemical testing. Gramstained smears of the positive blood culture and of colonies growing on MacConkey agar (BBL) and on trypticase soy agar with 5% sheep blood (BBL) revealed gram-negative coccobacilli. The organism produced small, colorless colonies on MacConkey agar; on 5% sheep blood agar the colonies were 1 to 2 mm in diameter, circular, grayish-white and smooth in consistency. The results of the biochemical testing are listed in Table 1. As shown in the table, the organism produced an alkaline slant and acid butt on lysine-iron agar (LIA), indicative of inability to deaminate or decarboxylate lysine. The organism was able to decarboxylate ornithine but not arginine. Hydrogen sulfide was not produced, and the spot test for indole production was positive. Motility was negative at 37 C and positive at room temperature. The urease test was positive, but tests for DNase, oxidase, and phenylalanine deaminase and growth on citrate were negative. The organism fermented arabinose, sorbitol and mannitol, but not adonitol, inositol, raffinose and rhamnose. An acid slant and acid butt with no gas was produced in the TSI medium, which was evidence of sucrose, not lactose, fermentation. Confirmation of the identification of the bacterial isolate described here was performed by the Maryland State Department of Health. Antibiotic susceptibility testing was performed by an agar dilution method currently in use in the Microbiology Laboratory, The Johns Hopkins Hospital.6 Media were prepared by adding antibiotics to cooled, molten Mueller-Hinton agar (BBL) and dispensing into 10 x 10-cm square petri plates, approximately 35 ml per plate. The bacterial isolate selected for antibiotic susceptibility testing was inoculated into 2 ml
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THIS REPORT describes the isolation of Yersinia enterocolitica from the blood of a 5-week-old infant with sepsis. This organism, which culturally and biochemically may resemble other Enterobacteriaqeae, can cause a variety of infections in man. It has been reported to occur in association with mesenteric lymphadenitis, gastroenteritis, and arthritis in children, and septicemia, fever of unknown origin, arthralgia, and erythema nodosum in adults.'0 It appears that the association with acute gastroenteritis occurs most commonly in young children.101318 This case is of special interest since it involves an infant with septicemia and fever, but with little gastrointestinal involvement.
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of Mueller-Hinton broth (BBL), incubated for 2 hours in a 37 C water bath, and then adjusted with saline solution to the turbidity of a 0.5 McFarland standard, representing approximately 108 organisms per ml. Using a Steers replicating device, 22 which can be used to inoculate 36 isolates simultaneously onto a single plate of medium, 0.01 ml of a 1:10 dilution of the standardized suspension of organism was spotted onto the surface of the medium, with the final inoculum size being 10' organisms. The diluted bacterial suspension was subcultured onto trypticase soy agar with 5% sheep blood and incubated at 37 C for 18 hours to confirm purity of the culture.
Discussion Yersinia enterocolitica was first recognized in the United States in 1933 and was first reported in 1939.421 In the years 1947 to 1966, no case of human infection with this organism was recognized in the United States, and between 1966 and 1972, only 29 culture-proven Yersinia enterocolitica infections are known to have occurred. 212(i In Europe, however, 1,000 cases pf infection with this microorganism were diagnosed between 1964 and 1971.,4-21 Yersiniosis in Finland has frequently been described, 2 ' 0 2 3 and reports of infections have come from Denmark, 23 England, 8 and Sweden. 15 Outside of Europe, Yersinia infections have been reported from South Africa16 and Australia." In one discussion of the geographical distribution of Yersinia enterocolitica, it was noted that the organism was found predominantly in Western Europe, especially in Sweden, Belgium, France, Denmark, Finland and Switzerland, and also in Central Europe, in Czechoslovakia, Rumania, and the U.S.S.R. 16 Only sporadic cases were observed in the United States. Recently, however, 24 human isolates of Yersinia enterocolitica submitted to the California Department of Health from 1968 to 1975 were described. 3 A survey of the incidence of Yersinia enterocolitica infection in Canada revealed 256 human and 22 non-human isolates. 24 It is interesting that the common serotypes of
Concentrations Tested (^g/ml) Tetracycline Chloramphenicol Cephalothin Ampicillin Gentamicin Kanamycin Amikacin
1, 2, 4, 16 2, 4, 8 2, 8, 32 1, 2, 4, 16 1, 2, 4, 8 2, 4, 8, 16 2, 4, 8, 16
MIC (/xg/ml) 2 4 32 16 I 4 2
Yersinia enterocolitica repeatedly isolated in Europe and Canada are serotypes 3 and 9, while serotype 8 is seen most commonly in the United States. 3 In the cases isolated from South Africa, serotype 3 was reported. 17 These findings may suggest that there are differences in the epidemiologies of Yersinia enterocolitica infections in the United States and other countries. The apparent low incidence of isolation of Yersinia enterocolitica in the United States may be due to three factors: (1) it may not actually have the same geographic distribution in the United States that it has in other countries; (2) it may not be recognized by current identification procedures used in many laboratories; (3) it may be recognized but not reported or sent for confirmation to state laboratories or to the Center for Disease Control. This lack of recognition of infections caused by Yersinia enterocolitica may, in turn, be attributed to (1) the difficulty in the isolation and differentiation from other members of the family Enterobacteriaceae, and (2) the lack of awareness of the association of Yersinia with disease other than mesenteric lymphadenitis. Yersinia enterocolitica may be isolated from a variety of clinical sources, including blood, cerebrospinal fluid, urine, eye, stool, throat, trachea, and wound specimens. 4 2 0 A hepatosplenic abscess due to Yersinia enterocolitica has been described, 17 and the organism has also been cultured from enteric contents of patients with symptoms suggesting acute appendicitis. 15 Septicemia due to Yersinia enterocolitica has been described infrequently, but four cases were reported during the period 1971-1975. 15 - 712 All of these occurred in patients more than 65 years old. In all four cases, the patients were febrile but did not have gastrointestinal involvement. In addition, although it has generally been accepted that most cases of septicemia due to Yersinia enterocolitica are associated with an underlying disease, all of these cases occurred in patients with no recognized underlying illness. The infant described in this report was not known to have any underlying disease. It is uncertain whether there was any relationship between the Salmonella infantis subsequently isolated
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The seven antibiotics tested were tetracycline, chloramphenicol, cephalothin, ampicillin, gentamicin, kanamycin, and amikacin. Results were expressed as the minimum inhibitory concentration of the antibiotic tested in micrograms per milliliter. The concentrations of the antibiotics tested and the antibiotic susceptibility pattern of the Yersinia enterocolitica isolate described here are shown in Table 2. The organism appeared to be moderately resistant to ampicillin and cephalothin and sensitive to tetracycline, chloramphenicol, gentamicin, kanamycin and amikacin.
Table 2. Antibiotic Susceptibility of Yersinia enterocolitica Isolate
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from this patient's stool and the previous infection with Yersinia enterocolitica. Concurrent infections with Yersinia enterocolitica and other enteric pathogens have been described. 161819 One report recorded an infection with Yersinia enterocolitica in an infant with enteritis who also had enteropathogenic Escherichia coli isolated from his stools.1!) Another report described two patients with gastroenteritis, both of whom had Yersinia enterocolitica isolated from their stools concurrently with Salmonella montevideo and an enteropathogenic Escherichia coli, respectively. 16 Additional enteric pathogens, two Salmonella organisms and one Shigella, were reported to be isolated from three patients with Yersinia enterocolitica infection.18
Dr. Patricia Charache reviewed the manuscript.
References 1. Abramovitch H, Butas C: Septicemia due to Yersinia enterocolitica. Can Med Assoc J 109:1112, 1973 2. Ahvonen P: Human yersiniosis in Finland. 1. Bacteriology and serology. Ann Clin Res 4:30-38, 1972 3. Bissett ML: Yersinia enterocolitica isolates from humans in California, 1968-1975. J Clin Microbiol 4:137-144. 1976 4. Bottone EJ, Chester B, Malowany MS, et al: Unusual Yersinia enterocolitica isolates not associated with mesenteric lymphadenitis. Appl Microbiol 27:858-861, 1974 5. ChessumB, FrengleyJD, Fleck DG,etal: Case of septicemia due to Yersinia enterocolitica. Br Med J 3:466, 1971 6. Ericcson HM, Sherris JC: Antibiotic sensitivity testing. Report of an international collaborative study. Acta Pathol Microbiol, Sect B, suppl 217. Copenhagen, Munksgaard, 1971 7. Eriksson M, Olcen P: Septicemia due to Yersinia enterocolitica in a non-compromised host. Scand J Infect Dis 7:78-80. 1975 8. Gurry JF: Acute terminal ileitis and Yersinia infection. Br Med J 2:264-265, 1974 9. Gutman LT, Ottesen EA. Quan TJ, et al: An inter-familial outbreak of Yersinia enterocolitica enteritis. N Engl J Med 288:1372-1376, 1973 10. Hallstrom K, Sairanen E, Ohela K: A pilot clinical study on yersinioses in south-eastern Finland. Acta Med Scand 191:485-491, 1972 11. Hewstone AS, Davidson GP: Yersinia enterocolitica septicemia with arthritis in a thalassemic child. Med J Aust 1:1035-1038. 1972 12. Josefson K, Lindberg A: Fatal Yersinia enterocolitica septicemia. Scand J Infect Dis 7:76-77, 1975 13. Kohl S, Jacobson JA, Nahmias A: Yersinia enterocolitica infections in children. J Pediatr 89:77-79, 1976 14. Mollaret HH: Human Yersinia enterocolitica infections in 1970. Report of 642 recent cases. Clinical and epidemiological aspects. Pathol Biol 19:189-205, 1970 15. Nilehn B: Studies on Yersinia enterocolitica. Acta Pathol Microbiol Scand 69:83-91, 1967 16. Rabson AR, Koornhof HJ: Yersinia enterocolitica infections in South Africa. South Afr Med J 46:798-803, 1972 17. Rabson AR, Koornhof, HJ, Notmen J, et al: Hepatosplenic abscesses due to Yersinia enterocolitica. Br Med J 4:341, 1972 18. Randall C, Bannatyne RM: Experience with Yersinia enterocolitica at the hospital for sick children. 1972-74. Can Med Assoc J 113:542-543, 1975 19. Shieven BC, Randall C: Enteritis due to Yersinia enterocolitica. J Pediatr 84:402-404, 1974 20. Sonnenwirth A: Bacteremia with and without meningitis due to Yersinia enterocolitica. Edwardsiella tarda. Coinamonas terrigena, and Pseudomonas nuiltophilia. Ann NY Acad Sci 174:488-494, 1970 21. Sonnenwirth AC: Yersinia. Manual of Clinical Microbiology. Second edition. Edited by Lennette EH, Spaulding EH, Truant JP. American Society for Microbiology, Washington, D.C., 1974, pp 226-229 22. Steers E, Foltz EL, Graves BS, et al: An inocula replicating apparatus for routine testing of bacterial susceptibility to antibiotics. Antibiot Chemother 9:307, 1959 23. ToivanenP, OlkkanenL,Toivanen A,et al: Hospital outbreak of Yersinia enterocolitica infection. Lancet 1:801-803, 1973 24. Toma S, Lafleur L: Survey on the incidence of Yersinia enterocolitica infection in Canada. Appl Microb 28:469-473, 1974 25. von Knorring J, Pettersson T: Haemolytic anemia complicating Yersinia enterocolitica infection. Scand J Haematol 9:149152, 1972 26. Weaver RE, Jordan JG: Recent human isolates of Yersinia enterocolitica, Contributions to Microbiology and Immunology. Vol. 2. Edited by Winblad S. Basel, S. Karger, 1973, pp 120-125
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The presence of Yersinia enterocolitica in many animal species suggests that the disease is a zoonosis. 16 It has been recovered from a large variety of animal species, including chinchillas, hares, monkeys, antelopes, horses, dogs and pigs.8-24 A pet dog present in the household occupied by the infant described here was not tested for carrier state. Some investigators consider the dog to be the most likely source of infection for man, while others consider the pig to be the main source of human infection. 914 Only the pig has regularly been found to carry one of the same serologic groups as that found in man (serotype 3), and the organism has been recovered from the stools and mesenteric lymph nodes of apparently healthy pigs. In addition, the geographic distribution of porcine strains of Yersinia enterocolitica, as shown by phage typing, corresponds to that found for man. 16 However, in spite of this evidence, there is still no definite proof of a connection between human and animal illness. Also, because of the finding of symptomless carriers, man himself may prove to be an important reservoir of Yersinia enterocolitica.I6 The portal of entry of Yersinia enterocolitica appears to be the digestive tract. This corresponds well with the frequency of digestive symptoms, the high incidence of lesions in the ileum, appendix and mesenteric lymph nodes and the seasonal incidence, which tends to follow that of other gastrointestinal diseases. 16 The case reported here, however, occurred in a patient with little gastrointestinal involvement and none of the lesions mentioned above. It is, therefore, uncertain what the portal of entry might have been. Suggested possibilities for transmission of Yersinia enterocolitica include: (1) ingestion of contaminated food; (2) contact with an infected animal such as a pet; (3) person-to-person transmission through hand-tomouth contact in an infected family.9 Acknowledgment.
A.J.C.P. • February 1978
CAPLAN, DOBSON AND DORKIN
