History and Physical Examination
The usual presentation of Y enterocolitica infection includes diarrhea (the most common clinical manifestation of this infection), low-grade fever, and abdominal pain lasting 1-3 weeks. Diarrhea may be bloody in severe cases. Vomiting is present in approximately 15-40% of cases.
The existence of extraintestinal symptoms after a gastrointestinal illness also may indicate the possibility of yersiniosis.
Enterocolitis
Enterocolitis, the most common presentation of Y enterocolitica, 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 white blood cells (WBCs) in the stool (25%). The diarrhea generally has a duration of 1 day to 3 weeks.
Most cases are self-limited. However, concomitant bacteremia may occur in 20-30% of infants younger than 3 months.
Complications of enterocolitis include appendicitis, [42] diffuse ulceration and inflammation of the small intestine and colon, peritonitis, [44, 45] meningitis, intussusception, [46] and cholangitis.
Mesenteric adenitis, mesenteric ileitis, and acute pseudoappendicitis
These manifestations are characterized by the following symptoms (although nausea, vomiting, diarrhea, and aphthous ulcers of the mouth also can occur):
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Fever
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Abdominal pain
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Tenderness of the right lower quadrant
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Leukocytosis
Pseudoappendicitis syndrome is more common in older children and young adults. [47] Patients with Y enterocolitica infection often undergo appendectomy; several Scandinavian studies suggested a prevalence rate of 3.8-5.6% for infection with Y enterocolitica in patients with suspected appendicitis.
Analysis of several common-source outbreaks in the United States found that 10% of 444 patients with symptomatic, undiagnosed Y enterocolitica infection underwent laparotomy for suspected appendicitis.
Reactive arthritis
This is associated with HLA-B27 (found in approximately 80% of affected patients). Most commonly reported in Scandinavia, polyarticular arthritis can occur after Y enterocolitica infection. Joint symptoms, which occur in approximately 2% of patients, typically arise 1-2 weeks after gastrointestinal illness. [15]
The large joints of the lower extremities are involved most commonly, and symptoms usually persist for 1-4 months, although reports document prolonged syndromes.
Myocarditis and glomerulonephritis
These are other postinfection sequelae associated with the HLA-B27. [48]
Erythema nodosum
This manifests as painful, raised red or purple lesions, mainly on the patient’s legs and trunk. Lesions appear 2-20 days after the onset of fever and abdominal pain and resolve spontaneously in most cases in about a month. The female-to-male ratio of erythema nodosum is 2:1, and it is more common in adults than in children.
Septicemia
In this, a bacteremic spread to extraintestinal sites occurs, resulting in critical illness. Y enterocolitica septicemia is reported most commonly in patients who have predisposing conditions, including alcoholism, diabetes mellitus, or an underlying immune defect.
Patients with iron overload conditions and those who are undergoing treatment with deferoxamine also are at an increased risk for septicemia, secondary to the effect of iron on the virulence of the bacteria. [16]
In addition, Y enterocolitica septicemia usually is reported in patients with a hematologic disease, such as thalassemia, sickle cell disease, or hemochromatosis. [16, 49, 50, 51] Elderly patients and those who are malnourished also are at increased risk of developing septicemia.
Metastatic infections following Y enterocolitica septicemia include focal abscesses in the liver, kidneys, spleen, and lungs. Cutaneous manifestations include cellulitis, pyomyositis, pustules, and bullous lesions. Pneumonia, meningitis, panophthalmitis, endocarditis, infected mycotic aneurysm, and osteomyelitis also may occur. [48]
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Yersinia enterocolitis in a 45-year-old white woman who presented with chronic diarrhea.
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Gram stain of Yersinia enterocolitica.
