eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Yersinia Enterocolitica Infection

Author: Swetha G Pinninti, MD, Resident, Department of Pediatrics, St Peter's University Hospital
Coauthor(s): Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine; Daniel R Bronfin, MD, Chief, General Academic Pediatrics, Ochsner Health System
Contributor Information and Disclosures

Updated: Jun 5, 2009

Introduction

Background

Yersinia enterocolitica is a well-described enteric pathogen with distinctive clinical manifestations, a range of outcomes, and a predilection for children. In 1939, Schleifstein and Coleman first described Y enterocolitica. Approximately 75% of patients with Y enterocolitica infection are children aged 5-15 years. The spectrum of disease ranges from asymptomatic to life-threatening sepsis, especially in infants.

Gram stain of <em>Yersinia enterocolitica.</em>

Gram stain of Yersinia enterocolitica.

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Gram stain of <em>Yersinia enterocolitica.</em>

Gram stain of Yersinia enterocolitica.

Pathophysiology

This organism belongs to the family Enterobacteriaceae, genus Yersinia, which includes 11 species. Among them, only 3 species are pathogenic to humans: Yersinia pestis (bubonic plague), Yersinia pseudotuberculosis (mesenteric adenitis), and Y enterocolitica. Humans are accidental hosts. Yersinia species are gram-negative, oxidase-negative, and non–lactose-fermenting bacilli. 

Species are differentiated based on traits, such as urease positivity (Y enterocolitica is urease negative), motility (Y enterocolitica is motile at 22 o C), and sugar fermentation reactions. Biotyping and serotyping can be performed. Of the 34 serotypes of O antigen of Y enterocolitica, types 0:3 (sporadic cases in the United States);1 0:5,27; 0:8 (food-borne outbreaks in the United States); and 0:9 are the most common and represent the most virulent worldwide causes of human yersiniosis. Virulence factors can be chromosomal or plasmid-encoded. 

Y enterocolitica grows most efficiently in environments with a pH of 5-9, hence the increased incidence of the disease in patients who take antacids and histamine 2 blockers.2 The organism requires iron to survive, and Yersinia sepsis has been reported in clinical states of iron overload3 , such as hemochromatosis4 , and in children following accidental iron overdose. Y enterocolitica grows on basic enteric media, producing subtle pinpoint colonies after 24 hours of incubation. Optimally, if Y enterocolitica is suspected, cefsulodin-irgasan-novobiocin (CIN) agar should be used.

After ingestion of the organism, the terminal ileum is the site of mucosal adherence and penetration, followed by reproduction of the organism in Peyers patches. Nonspecific ileocolitis is often noted, with an inflammatory infiltrate in the lamina propria. The bacteria may then spread to the mesenteric lymph nodes; this spread may lead to bacteremia5 or to the development of abscesses and pain in the right lower quadrant that mimic the pain of appendicitis.6

Although Y enterocolitica does produce a heat-stable enterotoxin similar to that of Escherichia coli, the enterotoxin does not contribute to the pathogenicity of the organism. Plasmid-encoded proteins of the outer membrane represent a major determinant in the pathogenicity of Y enterocolitica by contributing to adherence and invasion of the organism; antibodies directed against these proteins are present in patients convalescing from disease.

Frequency

United States

Y enterocolitica infection is more common in cooler climates and its prevalence peaks from November to January.5 Y enterocolitica has been isolated in 1.4-2.8% of stools of children with diarrhea. Disease occurs in 1 person per 100,000 population per year in the United States.

International

Most frequently recognized in Northern Europe.

Mortality/Morbidity

The incubation period is 1-14 days and the duration of stool excretion is 14-97 days. Symptoms typically persist for 5-14 days.

Race

Higher incidence is observed among black infants.7

Sex

The male-to-female ratio is 1.7:1.

Age

Most infections occur in children younger than 7 years, with more severe infections in children less than 1 year of age.8

Clinical

History

Yersinia enterocolitica infection may be asymptomatic; however, several syndromes are associated with this infection in children.

  • Enterocolitis
    • Enterocolitis, the most common presentation, occurs primarily in young children, with a mean age of 24 months.
    • The incubation period is 4-6 days, typically with a range of 1-14 days.
    • Prodromal symptoms of listlessness, anorexia, and headache may be present. Such symptoms are followed by watery, mucoid diarrhea (78-96%); fever (43-47%); colicky abdominal pain (22-84%); bloody stools (<10%); and WBCs in the stool (25%).
    • Duration of diarrhea is generally 1 day to 3 weeks.
    • Concomitant bacteremia may occur in 20-30% of infants younger than 3 months.
    • Most cases are self-limited.
    • Complications include appendicitis,9 diffuse ulceration and inflammation of the small intestine and colon, peritonitis,10,11 meningitis, intussusception,12 and cholangitis.
  • Pseudoappendicitis syndrome
    • Characteristics include fever, abdominal pain, tenderness in the right lower quadrant, and leukocytosis.
    • This condition is predominantly reported in patients with Y pseudotuberculosis infection.
    • Infection causes mesenteric lymphadenitis with terminal ileitis.
    • Pseudoappendicitis syndrome is more common in older children and young adults.13
  • Bacteremia: Bacteremia is seen most frequently in very young infants and patients with iron-overload syndromes receiving frequent transfusion for sickle cell anemia,14 thalassemia,3  and hemochromatosis4 , as well as those receiving oral iron supplementation and those who experienced an unintentional iron overload. Both iron overload and treatment with desferrioxamine are predisposing factors.14  Treatment with desferrioxamine increases bioavailability of iron to Y enterocolitica.
  • Postinfectious, nonsuppurative sequelae: Such sequelae, which are uncommon, include reactive polyarthritis15 , erythema nodosum, and proliferative glomerulonephritis. These sequelae are most often seen in individuals with human leukocyte antigen (HLA)-B27.16 Long-term prognosis for this form of arthritis is good. Chronic inflammatory bowel disease has also been associated with Y enterocolitica infections.17

Physical

  • Clinically, suspect Y enterocolitica infection in children with watery, bloody, mucoid diarrhea; a positive stain for WBCs; and exposure to uncooked meat products, particularly pork.
  • Physical findings mimicking appendicitis may be noted.
  • Less commonly, pharyngitis, cellulitis, meningitis, conjunctivitis, pneumonia, arthritis, and erythema nodosum are observed.

Causes

  • Animal reservoirs
    • Swine (principle reservoir)
    • Cattle
    • Dogs
    • Rodents
    • Sheep
    • Cats
  • Transmission
    • Transmission is primarily via ingestion of contaminated foods, especially people who handle/eat pork. Chitterlings have been documented as a source of infection.18 Guidelines for the diagnosis and management of foodborne illnesses have been established.19
    • Pasteurized milk and dairy products can also cause outbreaks because Yersinia can proliferate at refrigerated temperatures.20
    • Fecal-oral transmission among humans has not been proven.
    • Transmission via blood products has occurred.21
    • Infection can be transmitted from mother to newborn infant.

More on Yersinia Enterocolitica Infection

Overview: Yersinia Enterocolitica Infection
Differential Diagnoses & Workup: Yersinia Enterocolitica Infection
Treatment & Medication: Yersinia Enterocolitica Infection
Follow-up: Yersinia Enterocolitica Infection
Multimedia: Yersinia Enterocolitica Infection
References
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References

  1. Lee LA, Taylor J, Carter GP, Quinn B, Farmer JJ 3rd, Tauxe RV. Yersinia enterocolitica O:3: an emerging cause of pediatric gastroenteritis in the United States. The Yersinia enterocolitica Collaborative Study Group. J Infect Dis. Mar 1991;163(3):660-3. [Medline].

  2. Tennant SM, Hartland EL, Phumoonna T, et al. Influence of gastric acid on susceptibility to infection with ingested bacterial pathogens. Infect Immun. Feb 2008;76(2):639-45. [Medline].

  3. Vento S, Cainelli F, Cesario F. Infections and thalassaemia. Lancet Infect Dis. Apr 2006;6(4):226-33. [Medline].

  4. Bergmann TK, Vinding K, Hey H. Multiple hepatic abscesses due to Yersinia enterocolitica infection secondary to primary haemochromatosis. Scand J Gastroenterol. Aug 2001;36(8):891-5. [Medline].

  5. Abdel-Haq NM, Asmar BI, Abuhammour WM, Brown WJ. Yersinia enterocolitica infection in children. Pediatr Infect Dis J. Oct 2000;19(10):954-8. [Medline].

  6. Antonopoulos P, Constantinidis F, Charalampopoulos G, Dalamarinis K, Karanicas I, Kokkini G. An emergency diagnostic dilemma: a case of Yersinia enterocolitica colitis mimicking acute appendicitis in a beta-thalassemia major patient: the role of CT and literature review. Emerg Radiol. Jul 10 2007;[Medline].

  7. Ray SM, Ahuja SD, Blake PA, et al. Population-based surveillance for Yersinia enterocolitica infections in FoodNet sites, 1996-1999: higher risk of disease in infants and minority populations. Clin Infect Dis. Apr 15 2004;38 Suppl 3:S181-9. [Medline].

  8. Koehler KM, Lasky T, Fein SB, et al. Population-based incidence of infection with selected bacterial enteric pathogens in children younger than five years of age, 1996-1998. Pediatr Infect Dis J. Feb 2006;25(2):129-34. [Medline].

  9. Lamps LW, Madhusudhan KT, Greenson JK, et al. The role of Yersinia enterocolitica and Yersinia pseudotuberculosis in granulomatous appendicitis: a histologic and molecular study. Am J Surg Pathol. Apr 2001;25(4):508-15. [Medline].

  10. De Berardis B, Torresini G, Brucchi M, et al. Yersinia enterocolitica intestinal infection with ileum perforation: report of a clinical observation. Acta Biomed. Apr 2004;75(1):77-81. [Medline].

  11. Reed RP, Robins-Browne RM, Williams ML. Yersinia enterocolitica peritonitis. Clin Infect Dis. Dec 1997;25(6):1468-9. [Medline].

  12. Hervas JA, Alberti P, Bregante JI, Boya E, Reina J, Gil J. Chronic intussusception associated with Yersinia enterocolitica mesenteric adenitis. J Pediatr Surg. Dec 1992;27(12):1591-2. [Medline].

  13. Chandler ND, Parisi MT. Radiological case of the month. Yersinia enterocolitica masquerading as appendicitis. Arch Pediatr Adolesc Med. May 1994;148(5):527-8. [Medline].

  14. Stoddard JJ, Wechsler DS, Nataro JP, Casella JF. Yersinia enterocolitica infection in a patient with sickle cell disease after exposure to chitterlings. Am J Pediatr Hematol Oncol. May 1994;16(2):153-5. [Medline].

  15. Taccetti G, Trapani S, Ermini M, Falcini F. Reactive arthritis triggered by Yersinia enterocolitica: a review of 18 pediatric cases. Clin Exp Rheumatol. Nov-Dec 1994;12(6):681-4. [Medline].

  16. Ström H, Johansson C. Appendicitis followed by reactive arthritis in an HLA B27-positive man after infection with Yersinia enterocolitica, diagnosed by serotype specific antibodies and antibodies to Yersinia outer membrane proteins. Infection. Sep-Oct 1997;25(5):317-9. [Medline].

  17. Saebo A, Vik E, Lange OJ, Matuszkiewicz L. Inflammatory bowel disease associated with Yersinia enterocolitica O:3 infection. Eur J Intern Med. Jun 2005;16(3):176-182. [Medline].

  18. Yersinia enterocolitica gastroenteritis among infants exposed to chitterlings--Chicago, Illinois, 2002. MMWR Morb Mortal Wkly Rep. Oct 10 2003;52(40):956-8. [Medline].

  19. [Guideline] CDC. Diagnosis and management of foodborne illnesses: a primer for physicians and other health care professionals. MMWR Recomm Rep. Apr 16 2004;53:1-33. [Medline].

  20. Tacket CO, Narain JP, Sattin R, et al. A multistate outbreak of infections caused by Yersinia enterocolitica transmitted by pasteurized milk. JAMA. Jan 27 1984;251(4):483-6. [Medline].

  21. Leclercq A, Martin L, Vergnes ML, et al. Fatal Yersinia enterocolitica biotype 4 serovar O:3 sepsis after red blood cell transfusion. Transfusion. May 2005;45(5):814-8. [Medline].

  22. Zheng H, Wang J, Sun Y, Jiang B. Clinical isolation and characterization of Yersinia enterocolitica in China using real-time PCR and culture method. Digestion. 2007;75(4):199-204. [Medline].

  23. Zheng HX, Sun Y, Jiang B. [Evaluation of 4 culture methods of Yersinia enterocolitica]. Nan Fang Yi Ke Da Xue Xue Bao. Sep 2007;27(9):1438-40. [Medline].

  24. Girszyn N, Kerleau JM, Robaday S, Lefebvre S, Marie I, Levesque H. [Pneumonia with bacteremia due to Yersinia enterocolitica in a diabetic patient carrying HLA-B27.]. Rev Med Interne. Dec 2007;28(12):882-884. [Medline].

  25. Hoelen DW, Tjan DH, Schouten MA, Dujardin BC, van Zanten AR. Severe Yersinia enterocolitica sepsis after blood transfusion. Neth J Med. Sep 2007;65(8):301-3. [Medline].

  26. Pulvirenti D, Aikaterini T, Neri S. Septicemia, hepatic abscess, and encephalitis due to Yersinia enterocolitica. J Clin Gastroenterol. Mar 2007;41(3):333-4. [Medline].

  27. Jess T, Jess P. Acute terminal ileitis, yersiniosis, and Crohn's disease: a long-term follow-up study of the relationships. Eur J Intern Med. Apr 2001;12(2):98-100. [Medline].

  28. Navarro-Llavat M, Domenech E, Masnou H, et al. Collagenous duodeno-ileo-colitis with transient IgG deficiency preceded by Yersinia enterocolitica intestinal infection: case report and review of literature. Gastroenterol Hepatol. Apr 2007;30(4):219-21. [Medline].

  29. Berner R, Kist M, Sauer M. Encephalopathy associated with Yersinia enterocolitica O:3. Lancet. Feb 7 1998;351(9100):418. [Medline].

  30. von Eckardstein K, Spuler A, Brauer C, Mehl M, Kiwit J. Spontaneous cervical osteomyelitis due to Yersinia enterocolitica in a non-immunocompromised host. Eur J Clin Microbiol Infect Dis. Jan 2004;23(1):66-8. [Medline].

  31. Krajinovic V, Tambic Andrasevic A, Barsic B. Tricuspidal valve endocarditis due to Yersinia enterocolitica. Infection. Jun 2007;35(3):203-5. [Medline].

  32. Kelesidis T, Balba G, Worthington M. Axillary abscess in a patient with Yersinia enterocolitica infection as a result of exposure to pork. Am J Med. Mar 2008;121(3):e1. [Medline].

  33. Mills DM, Meyer DR. Posttraumatic cellulitis and ulcerative conjunctivitis caused by Yersinia enterocolitica O:8. Ophthal Plast Reconstr Surg. Sep-Oct 2008;24(5):425-6. [Medline].

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Further Reading

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Keywords

Yersinia enterocolitica infection, Enterobacteriaceae, Y enterocolitica, yersiniosis, sepsis, Yersinia pestis, bubonic plague, Yersinia pseudotuberculosis, mesenteric adenitis, Yersinia sepsis, hemochromatosis, nonspecific ileocolitis, bacteremia, enterocolitis, appendicitis, peritonitis, meningitis, intussusception, cholangitis, pseudoappendicitis syndrome, mesenteric lymphadenitis, cellulitis, conjunctivitis, osteomyelitis, pharyngitis, pneumonia, pyomyositis, urinary tract infection, acute iron ingestion, sickle cell disease, thalassemia, reactive polyarthritis, erythema nodosum, proliferative glomerulonephritis, treatment, diagnosis

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Contributor Information and Disclosures

Author

Swetha G Pinninti, MD, Resident, Department of Pediatrics, St Peter's University Hospital
Swetha G Pinninti, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Coauthor(s)

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Daniel R Bronfin, MD, Chief, General Academic Pediatrics, Ochsner Health System
Daniel R Bronfin, MD is a member of the following medical societies: American Academy of Pediatrics and American Cleft Palate/Craniofacial Association
Disclosure: Nothing to disclose.

Medical Editor

Leonard R Krilov, MD, Chief of Pediatric Infectious Diseases, Vice Chair, Department of Pediatrics, Professor of Pediatrics, Winthrop University Hospital
Leonard R Krilov, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Medimmune Grant/research funds Cliinical trials; Medimmune Honoraria Speaking and teaching; Medimmune Consulting fee Consulting

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Joseph Domachowske, MD, Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York-Upstate Medical University
Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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