Pseudotuberculosis (Yersinia) Workup
- Author: Asim A Jani, MD, MPH, FACP; Chief Editor: Mark R Wallace, MD, FACP, FIDSA more...
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.
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.
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.
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
Blood, peritoneal fluid, pharyngeal exudate, and synovial fluid may yield the organism.
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 .
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.
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.
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.
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.
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.
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