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Pseudotuberculosis (Yersinia): Differential Diagnoses & Workup

Author: Asim A Jani, MD, MPH, FACP, Clinician-Educator and Epidemiologist, Consultant and Senior Physician, Florida Department of Health; Assistant Professor, University of Central Florida College of Medicine
Coauthor(s): Paul Chen, Public Health Intern, American Public Health Association
Contributor Information and Disclosures

Updated: Sep 8, 2008

Differential Diagnoses

Appendicitis
Neutropenic Enterocolitis
Clostridium Difficile Colitis
Pancreatitis, Acute
Crohn Disease
Sarcoidosis
Encephalitis
Sepsis, Bacterial
Enteropathic Arthropathies
Staphylococcal Infections
Erythema Multiforme (Stevens-Johnson Syndrome)
Toxic Shock Syndrome
Gastroenteritis, Bacterial
Typhoid Fever
Kawasaki Disease
Ulcerative Colitis
Leptospirosis
Meningitis

Other Problems to Be Considered

The main concern for differential diagnoses relates to the predominant presentation of Y pseudotuberculosis disease—the gastroenteritis and mesenteric lymphadenitis syndromes. However, given the other unusual forms, including the Izumi fever syndrome suggestive of atypical scarlet fever or rheumatologic complications, such as erythema nodosum and/or reactive arthritides, the corresponding differential diagnoses for such presentations would likely vary significantly.

In such cases, refer to the differential diagnosis including, but not necessarily limited to, the following:

Workup

Laboratory Studies

  • The laboratory diagnosis of Y pseudotuberculosis infection is a matter of confirming the presence of the organism to support the clinical diagnosis of the associated syndromes.
    • Because this is a bacterial infection and so should not affect sterile fluids, the acquisition by culture from sources such as blood, cerebrospinal fluid (CSF), peritoneal fluid, synovial fluid, or other organ-based biopsy (eg, intestinal tissue, skin) is confirmatory.
    • Aside from diagnostic measures that include serological tests (discussed below), researchers have also developed various polymerase chain reaction (PCR) methods that are sensitive, efficient, and accurate tools for identifying and serotyping Y pseudotuberculosis.
    • Histologic examination of specific tissue, such as mesenteric lymph nodes, may provide both pathologic and microbiologic evidence of the organism.
  • Microbiology: Y pseudotuberculosis belongs to the genus Yersinia, which has 2 other pathogenic species that infect humans— Y enterocolitica and Y pestis. Y pseudotuberculosis and Y pestis have a remarkable 97-100% homology. Y pseudotuberculosis is a gram-negative, non–lactose-fermenting coccobacillus that is chemically differentiated from other species (eg, Y enterocolitica) by its fermentation of sorbitol and ornithine decarboxylase activity, among other features. The optimum growth of yersinia occurs on MacConkey medium at 20-35°C. The organism is urease-positive.
    • Bacteriology: Y pseudotuberculosis is both aerobic and facultatively anaerobic; it is a gram-negative coccobacillus that grows slowly on blood and chocolate agar plates, forming small gray and translucent colonies at 24-72 hours. It has a good growth pattern on MacConkey or eosin-methylene blue (EMB) agar plates but is enhanced noticeably at lower temperatures (eg, 4°C cold enrichment in buffered saline) and is motile at temperatures lower than 28°C. Biochemically, it is oxidase-negative, urea-splitting, and catalase-producing, and it does not ferment lactose.
    • Stool: Isolation of organism from stool is difficult given the slow growth pattern and overgrowth of normal fecal flora. However, stool culture yield may be increased with cold enrichment, special culture media (eg, cefsulodin-Irgasan-novobiocin [CIN] agar), or alkali treatment, but these methods are generally not cost-effective.
    • Blood, peritoneal fluid, pharyngeal exudate, and synovial fluid may yield the organism.
  • Serology
    • Enzyme-linked immunosorbent assay (ELISA) and agglutination tests may be obtained; the antibodies (against the O antigen) may appear soon after the onset of illness and typically wane over 2-6 months. Paired serum specimens taken 2 weeks apart that indicate a 4-fold rise in agglutinating antibodies support the diagnosis. Hemagglutination reaction tests that detect the pili (fimbriae) of either Y pseudotuberculosis or Y pestis have also been developed. Hemagglutination titers of 1:160 or higher are considered generally significant and indicative of true infection.
    • However, cross-reaction between antibodies against other organisms may obscure the diagnostic picture. These other organisms include other Yersinia, Vibrio, Salmonella, Brucella, and Rickettsia species.
    • Researchers have developed monoclonal antibodies that can identify serogroup-specific protein epitopes of Y pseudotuberculosis strains (grown at specific temperatures) from each of the 6 serogroups of the species. These monoclonal antibodies have been shown to not positively react with other Yersinia, Salmonella, Shigella, Escherichia, and Proteus species. This research has great potential to be developed into a potent serotyping tool for Y pseudotuberculosis.
    • A technique known as sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) has been shown to be a reliable serologic procedure for diagnosis of Y pseudotuberculosis or Y enterocolitica infection .

Imaging Studies

  • In patients with mesenteric lymphadenitis, CT scans and, in some cases, ultrasonography of the abdomen and pelvis may reveal enlarged mesenteric lymph nodes and/or peritoneal findings, including appendiceal inflammation, peri-appendiceal fluid, and/or terminal ileitis.
  • In patients with pneumonic or septic presentations, chest radiography may reveal infiltrates indicative of acute pneumonia.

Other Tests

In the unusual presentation of a Kawasaki disease–like variant—Izumi fever—ECG abnormalities may indicate ischemia if coronary artery circulation is compromised by aneurysms. These abnormalities are most likely to develop in children.

Procedures

Exploratory laparotomy is often needed in critically ill patients with prominent mesenteric lymphadenitis. Laparotomy serves both diagnostic and therapeutic purposes and enables actual intestinal and/or appendiceal tissue to be obtained and analyzed for histopathologic and microbiologic examinations.

Histologic Findings

Although the affected appendix may appear normal, involved lymph nodes (mesenteric) typically show epithelioid granulomatous changes, lymphoid hyperplasia, coagulative necrosis, and histiocytic cell hyperplasia. Enteric lesions may be associated with crypt hyperplasia, microabscesses, and villus shortening.

Staging

No staging is warranted in Y pseudotuberculosis infection. The most common forms of Y pseudotuberculosis infection include self-limited gastroenteritis or mesenteric lymphadenitis syndromes. Hosts with underlying diabetes, chronic liver disease (eg, chronic hepatitis), hemochromatosis, or immunosuppression may have sepsis accompanied by systemic disease. However, this is not common.

More on Pseudotuberculosis (Yersinia)

Overview: Pseudotuberculosis (Yersinia)
Differential Diagnoses & Workup: Pseudotuberculosis (Yersinia)
Treatment & Medication: Pseudotuberculosis (Yersinia)
Follow-up: Pseudotuberculosis (Yersinia)
References
Further Reading
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Further Reading

The reader may find the following texts useful:

The Genus Yersinia:  From Genomics to Function
Series: Advances in Experimental Medicine and Biology, Vol. 603
Perry, Robert D.; Fetherston, Jacqueline D. (Eds.)
2007, XXIV, 432 p. 242 illus., 2 in color., Hardcover
ISBN: 978-0-387-72123-1

Yersinia enterocolitica and Yersinia pseudotuberculosis Infections (Enteritis and Other Illnesses) In: Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006:[732-4]

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Keywords

Yersinia pseudotuberculosis, Y pseudotuberculosis, Y pseudotuberculosis gastroenteritis, Far East scarlet-like fever, FESLF, scarlatinoid fever, scarlet fever, Izumi fever, YPM, YPMa, YPMb, YPMc, Kawasaki disease, Pasteurella pseudotuberculosis, P pseudotuberculosis, Shigella pseudotuberculosis, S pseudotuberculosis, Bacillus pseudotuberculosis, B pseudotuberculosis, Yersinia infections, Yersinia mesenteric adenitis

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Contributor Information and Disclosures

Author

Asim A Jani, MD, MPH, FACP, Clinician-Educator and Epidemiologist, Consultant and Senior Physician, Florida Department of Health; Assistant Professor, University of Central Florida College of Medicine
Asim A Jani, MD, MPH, FACP is a member of the following medical societies: American College of Physicians, American Medical Association, American Public Health Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Paul Chen, Public Health Intern, American Public Health Association
Disclosure: Nothing to disclose.

Medical Editor

Douglas A Drevets, MD, Assistant Professor, Department of Medicine, Section of Infectious Disease, Oklahoma University Health Sciences Center
Douglas A Drevets, MD is a member of the following medical societies: American Association of Immunologists, American Society for Microbiology, Central Society for Clinical Research, and Christian Medical & Dental Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Joseph F John Jr, MD, FACP, FIDSA, FSHEA, Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center
Disclosure: BioMerieux Honoraria Review panel membership; Cubist Honoraria Review panel membership; Pfizer Honoraria Speaking and teaching; Merck Stock dividends stock holdings

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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