Pseudotuberculosis (Yersinia pseudotuberculosis Infection) Clinical Presentation

Updated: Oct 11, 2017
  • Author: David R Haburchak, MD, FACP; Chief Editor: Mark R Wallace, MD, FACP, FIDSA  more...
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Presentation

History

Symptoms caused by Y pseudotuberculosis infection include abdominal pain (often right lower quadrant location) and fever, usually with diarrhea. A 1984 series of 19 cases from Finland had the following distribution of symptoms: abdominal pain (14), fever (11), gastroenteritis (4), pseudoappendicitis (3), and none (2). Late complications of yersinial infection in this series included erythema nodosum (6), reactive arthritis (4), iritis (1), and nephritis (1). [1]

Other clinical problems associated with the enteric form of Y pseudotuberculosis infection have included terminal ileitis and intussusception, especially in children. Illness typically last 1-3 weeks, but symptoms may persist in some patients for months.

Far East scarlet fever–like syndrome, associated with specific superantigen-containing Russian and Japanese strains of Y pseudotuberculosis, has been characterized by Zalmover in 570 patients as a six-stage illness, as follows: [2, 16]

  • The incubation period of 7-10 days causes no symptoms.
  • Initial onset is characterized by fever, rigors, headache, myalgia, arthralgia, asthenia, and anorexia and manifests as a red face and neck, pale nasolabial triangle, conjunctival hyperemia, coryza, and abdominal pain.
  • The accrual phase occurs three days after symptom onset and manifests as increasing pain, fever, and the scarlet fever–like rash. Gastritis, ileitis, cholecystitis and mesenteric adenitis may occur, and right lower quadrant pain may mimic appendicitis. Hepatitis is common, as are central nervous symptoms of weakness, headache, photophobia, and vomiting.
  • Remission follows, with decreased severity of symptoms.
  • Recurrence and exacerbation may occur at day 8 or later and manifests as a return of pain, desquamation of skin, and increased jaundice, but absence of fever.
  • Convalescence ensues with resolution of all major symptoms by day 12.

Other manifestations of Y pseudotuberculosis infection may include erythema nodosum, arthralgias, reactive arthritis, and ankylosing spondylitis.

A food history is important, as Y pseudotuberculosis infection has been associated with ingestion of contaminated food items, including fresh produce (eg, raw carrots). Physicians who suspect this disease should inquire of other persons who may have also been infected in order to document a potential point-source outbreak to public health authorities.

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Physical

Physical findings caused by Y pseudotuberculosis infection may be grouped into 3 main categories—systemic, enteric, and rheumatologic. The predominant and often self-limited presentation of Y pseudotuberculosis infection is that of a febrile gastroenteritis with right lower quadrant abdominal pain.

Systemic findings may include fever, skin rash, strawberry tongue, hypotension, and lymphadenopathy.

Enteric findings include abdominal tenderness with or without rebound indicative of peritoneal involvement. Tenderness may be exquisite over McBurney point.

Rheumatologic involvement may include joint effusion, tenderness, or decreased range of movement and may be asymmetric in distribution.

Erythema nodosum lesions (often erythematous indurated tender areas on the anterior surface of the lower extremities) may be found.

Ophthalmic findings such as uveitis and conjunctivitis have also been reported.

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Causes

Yersinia species can carry a wide variety of virulence factors that allow for adhesion, invasion, suppression of host response, and dissemination. Different strains carry different factors, producing a pattern of systemic, enteric, and immune-mediated responses also dependent on host susceptibility and immunologic endowment.

Most notable among strains found in eastern Eurasia is Mitogen A, which acts as a superantigen similar to those associated with toxic shock syndromes caused by Staphylococcus aureus and group A Streptococcus. To date, Y pseudotuberculosis is the only know gram-negative organism to exhibit superantigen activity.

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Physical Examination

Vital signs in patients with Y pseudotuberculosis infection may demonstrate signs of sepsis. Abdominal tenderness should be elicited, especially in the right lower quadrant.

Skin and joint examination are important for evidence of rash (erythema nodosum or scarlet fever–like rash) or arthritis.

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Complications

Complications of Y pseudotuberculosis infection may include intussusception, bacteremia, septic arthritis, and disseminated infection, especially in immunocompromises or iron-overloaded patients.

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