Yersinia enterocolitica infections in children

Volume 89 Number 1

Brief cfinical and laboratory observations

cocci by counterimmunoelectrophoresis, J Immunol 110:1702, 1973. 10. Wilkinson HW, Thacker LG, and Facklam RR: Nonhemolytic group B streptococci of human, bovine, and ichthyic origin, Infect Immun 7:496, 1973. 11. Standardized disc susceptibility test, Fed Register 37:20527, 1972.

Yersinia enterocolitica

infections in children Steve Kohl, M.D.,* Jay A. Jacobson, M.D., and Andr6 Nahmias, M.D., Atlanta, Ga.

Y E R S I N I A ENTEROCOLITICA is associated with several clinical syndromes. It has received increasing attention in recent years f r o m E u r o p e a n a n d C a n a d i a n physicians w h o regard it as a relatively c o m m o n cause o f gastroenteritis a n d severe a b d o m i n a l p a i n in c h i l d r e n in certain c o u n t r i e s . " A l t h o u g h several cases a n d a n o u t b r e a k h a v e b e e n r e p o r t e d f r o m the U n i t e d States? -8 the incidence o f Y. enterocolitica infections in this c o u n t r y is not known. D u r i n g a 6 - m o n t h p e r i o d in 1975, however, four c h i l d r e n with Y. enterocolitica infection were diagnosed in two A t l a n t a hospitals. T h e cases show t h a t the diagnosis can b e readily m a d e w h e n physicians a n d laboratory p e r s o n n e l suspect it.

CASE REPORTS Case 1. A 19-month-old white female was hospitalized with a one-day history of fever, coryza, and a seizure. Positive physical findings were irritability and fever of 41 °C. Hem atocrit value was 29%, white blood cell count 8,700/mm 3 with 11% bands, 50% polymorphonuclear leukocytes, 31% lymphocytes, 7% monocytes, and 1% eosinophils. Shortly after admission diarrhea began with green, watery, fonl-smelling, non-bloody stools. Ampicillin was administered for presumed shigellosis. Four days later a pink, macular rash with target lesions developed on the trunk and limbs. Because stool cultures were negative for Salmonella and Shigella, ampicillin was discontinued. Within the ensuing five From the Division of Infectious Disease and Immunology, Department of Pediatrics, Emory University School of Medicine, and Special Pathogens Branch, Bacterial Diseases Division, Bureau of Epidemiology, Center for Disease Control. Dr. Kohl is supported by Research FellowshipAward CA 05232-01 from the National Cancer Institute. *Reprint address: Department of Pediatrics, Emory University School of Medicine, 69 Butler Street, S.E., Atlanta, Ga. 30303.

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12. Butter MNW, and de Moor CE: Streptococcus agalactiae as a cause of meningitis in the newborn, and of bacteremia in adults, Antonie van Leeuwenhoek 33:439, 1967. 13. Lancefield RC: Loss of the properties of hemolysin and pigment formation without change in immunological specificity in a strain of Streptococcus haemolyticus, J Exp Med 59:459, 1934.

days all symptoms resolved without specific therapy. During the patient's illness the possibility of yersiniosis was discussed with the laboratory and a second stool culture was submitted. Y. enterocolitica, resistant to ampicillin arid cephalothin and sensitive to chloramphenicol, tetracycline, kanamycin, and gentamicin, was recovered. The organism agglutinated with antisera to 0 factors 13 and 18. Case 2. A 19-month-old male cousin of Case 1 was seen with a four-day history of fever, green watery diarrhea and targetlike rash on the legs and abdomen. The temperature was 40~C with no other physical findings. The WBC was 14,800/mm 3 with many young forms and 6% eosinophils. Ampicillin therapy was prescribed for suspected otitis media. Within two days all symptoms resolved. A stool culture was obtained on a follow-up visit one month later because of the child's association with Case 1. Y. enterocolitica possessing 0 factors 13 and 18 was isolated.

Abbreviations used WBC: white blood count PMN: polymorphonuclear leukocytes

Case 3. A 4-year-old male presented with a 10-day history of fever, mild respiratory symptoms, and intermittent crampy lower abdominal pain unaccompanied by vomiting or diarrhea. His symptoms were unaffected by a four-day course of ampicillin administered in the week prior to admission. A temperature of 38.3°C was the only positive physical finding. The WBC was 24,900/mm 3 with 2% bands, 75% PMN, 15% lymphocytes, 8% monocytes, and 1% eosinophils. A stool culture grew Y. enterocolitica, sensitive to ampicillin, kanamycin, tetracycline, gentamicin, chloramphenicol, and colistin and resistant to cephalothin. Symptoms resolved over the following three days without specific antibiotic therapy. Case 4. A 3-month-old white female was transferred to an Atlanta hospital after in-patient evaluation at a local hospital failed to disclose the cause of her 21/i-month history of persistent diarrhea. The infant appeared chronically ill with an erythematous, scaly rash on her perineum; the abdomen was protuberant, and bowel sounds were absent. Body temperature was 37.2°C. The WBC was 13,000/ram ~ with 21% bands, 49% PMN, 25% lymphocytes, 5% monocytes, and 28,000 platelets/mm ~. Burr cells were seen on smear. Abdominal roentgenogram showed distended loops of bowel with air fluid levels. Laparotomy revealed matted loops of small bowel and purulent peritoneal fluid. A partial resection of the small bowel, ileostomy, and

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Brief clinical and laboratory observations

The Journal of Pediatrics July 1976

Table I. Clinical syndromes associated with Yersinia enterocolitica

Patient category

Characteristic syndrome

Children less than 5 years old Older children and adolescents

Fever, gastroenteritis Abdominal pain (pseudoappendicitis) Gastroenteritis Erythema nodosum, arthritis

Adults

Persons with altered host defenses Undefined

Septicemia Ophthalmitis, meningitis, cutaneous ulcers, carditis

Table I1. Characteristics of Yersinia enterocolitica useful in presumptive laboratory identification

Characteristic

Comment

[ Reference

Morphology Gram-negative coccobacillary; oval or rod shaped Growth Aerobic, facultatively anaerobic 9, Isolation Growth on blood agar and selective 4, 9, 12, enteric media; isolation from mixed cultures improved by cold enrichment Motility Motile at 22-25~ nonmotile 9. above 30~ Biochemistry Fermentative, lactose negative, ure4, 9, ase positive, oxidase negative, TSI acid/acid, no H2S, phenylalanine negative, biotyping is possible Serology Classifiable by agglutination or hemagglutination with antisera to O and H antigens

12 12 14

12 12

13

gastrostomy were performed. Therapy included intravenous ampicillin, gentamicin, and chloramphenicol. The patient's course was complicated by disseminated intravascular coagulation and oligufia, and on the eighth postoperative day she died: Initial blood and stool cultures grew Y. enterocolitica, 0 factor 18, resistant to ampicillin, cephalothin, and carbenicillin and sensitive to chloramphenicol, gentamicin, kanamycin, polymyxin, and tetracycline. Cultures of peritoneal fluid grew mixed gramnegative flora. Pathologic examination of the resected bowel showed suppurative inflammatory bowel disease with microabscesses of the lymph nodes and serosa. DISCUSSION Case reports of Y. enterocolitica have accumulated rapidly in the past decade, primarily from northern Europe, but the organism has been recovered from patients and environmental sources throughout the world. It has been found in untreated water and in wild and domestic animals. 4 Probable person-to-person, animal-toman, and food-borne transmission has been described

Diagnostic aids

References

WBC, stool culture WBC, stool culture; culture and biopsy.of mesenteric lymph nodes WBC, stool culture Stool culture and serology, particularly for serogroups 3 and 9 Blood culture, stool culture

1, 2 1, 2, 9

Culture of appropriate Site, serology

1,7,10

1, 2, 10 1, 2, 10 1, 11

and infection from contaminated water d o c u m e n t e d ? Epidemiologic investigation of our first two patients, who lived in the same household, failed to implicate food, water, and domestic animals as the likely source of infection, b u t revealed that the children's grandmother was an asymptomatic carrier of Y. enterocolitica. The mother of our fourth patient had a bout of diarrhea that coincided with her daughter's illness and she reported that an untreated stream was the source of water for the family. Our patients illustrate the characteristic syndromes of Y. enterocolitica infection which usually vary with age (Table I). Young children typically have fever and mildto-moderate, self-limited gastroenteritis. Case 4 is unusual because the patient was younger than children previously reported with yersiniosis and because her illness was progressive and complicated by bacteremia and probable intestinal perforation. A b d o m i n a l pain with mesenteric lymphadenitis or terrn'irial ileitis, occasionally mimicking appendicitis, occurs more commonly in older children. Leukocytosis a n d / o r ar~ increase in young white blood cells are generally present. The erythema multiforme,like rash seen in the first two cases may be a manifestation of Y. enterocolitica infection. Although the rash of the first patient was temporally related to ampicillin therapy, identical lesions appeared on the second patient before treatment. Recovering and identifying Y. enterocolitica from usually sterile sources such as blood is straightforward, but isolating it from stool m a y be more difficult because of overgrowth of other organisms and because it may be initially confused with other enteric bacteria such as Proteus. Cold enrichment and use of the screening characteristics listed in Table II should reduce this difficulty. H u m a n serology has been of diagnostic value primarily in European adults following infection with two serogroups, 3 and 9, which have not been encountered in the United States. There is little helpful information available on the

Volume 89 Number 1

Brief clinical and laboratory observations

m a n a g e m e n t o f yersiniosis. Patients with positive stool cultures should b e appropriately isolated a n d the source of their infection investigated. T h e efficacy of antibiotics in Y. enterocolitica gastroenteritis is u n k n o w n as is their effect on the c a r r i e r state. Patients with chronic or f u l m i n a n t illness would p r e s u m a b l y benefit f r o m specific antibiotic t r e a t m e n t b u t t h e r a p y should b e guided b y in vitro susceptibility testing o f the isolate. Such tests generally indicate sensitivity to c h l o r a m p h e n i c o l , tetracycline, colistin, gentamicin, a n d k a n a m y c i n . A l t h o u g h the incidence o f Y. enterocolitica infections in the U n i t e d States r e m a i n s u n k n o w n , increased awareness by physicians a n d laboratory p e r s o n n e l should help to clarify its clinical i m p o r t a n c e . We thank Dr. Daniel B. Caplan and Dr. Elna Steres for permission to report Cases 3 and 4; Dr. William H. Matthews for reviewing the surgical pathology 6f'Case 3; and Mr. James Feeley and Mrs. Catherine Philips, Center for Disease Control, for assistance in verifying and serotyping case isolates.

REFERENCES 1. Mollaret HH: L'infection humainea "Yersinia enterocolitica" en 1970 a la lumiere de 642 cas r6cents, Path Biol 19:189, 1971. 2. Ahvonen P: Human yersiniosis in Finland, Ann Clin Res 4:39, 1972. 3. Delorme J, Laverdi6re M, Martineau B, and Lafleur L: Yersiniosis in children, Can Meal Assoc J 110:281, 1974.

A cute unilateral oculomotor palsy associated with ECHO 9 viral infection John R. Hertenstein, B.A., Harvey B. Sarnat, M.D.,* and Dennis M. O'Connor, M.D., St. Louis, Mo.

ACUTE OCULOMOTOR PALSY w i t h o u t o t h e r n e u r o logic deficits m a y be associated with h e a d t r a u m a , neoplasm, hypertension, arteriosclerosis, diabetes melliFrom the Departments of Neurology and Pediatrics, Saint Louis University School of Medicine and Cardinal Glennon Memorial Hospital for Children. *Reprint address: Section of Neurology, Princess Margaret Hospital for Children, Perth, WesternAustralia 6001.

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4. Toma S: Survey on the incidence of Yersinia enterocolitica in the Province of Ontario, Can J Public Health 64:477, 1973. 5. Keet EE: Yersinia enterocolitica septicemia-source of infection and incubation period identified, NY State J Med 74:2226, 1974. 6. Jacobs JC: Yersinia enterocolitica arthritis, Pediatrics 55:236, 1975. 7. Sonnenwirth AC: Bacteremia with and without meningitis due to Yersinia enterocolitica, Ann NY Acad Sci 174:488, 1970. 8. Gutman LT, Ottesen EA, Quan TJ, Noce PS, and Katz SL: An inter-familial outbreak of Yersinia enterocolitica enteritis, N Engl J Med 288:1372, 1973. 9. Nil6hn B: Studies on Yersinia enterocolitica with special reference to bacterial diagnosis and occurrence in human acute enteric disease, Acta Pathol Microbiol Scand 206(Suppl):5, 1969. 10. Leino R, and Kallinom~iki JL: Yersiniosis as an internal disease, Ann Intern Med 81:458, 1974. 11. Rabson AR, Hallett AF, and Koornhof H J: Generalized Yersinia enterocolitica infection, J Infect Dis 131:447, 1975. 12. Sonnenwirth AC: Yersinia, in Lennette EH, Spaulding EH,. and Truant JP, editors: Manual of clinical microbiology, ed 2, Washington, 1974, American Society for Microbiology, p 222. 13. Winblad S: Studies on the 0-serotypes of Yersinia enterocolitica, Contrib Microbiol Imnmnol 2:27, 1973. 14. Toma S, Detdrick VR: Isolation of Yersinia enterocolitica from swine, J Clin Microbiol 2:478, 1975.

tus, aneurysms, pyogenic a n d tuberculous meningitis, a n d viral infections. This report describes a child with s u d d e n unilateral ptosis a n d external o p h t h a l m o p l e g i a associated with systemic E C H O 9 viral infection. Abbreviation used GMK: green monkey kidney C A S E REPORT An 18-month-old boy was admitted to Cardinal Glennon Memorial Hospital for Children in July, 1975, one day after the acute onset of drooping of the left eyelid. Five days earlier he had become irritable and anoretic with nausea and vomiting, followed in two days by the development of a macular erythematous rash on the trunk, neck, and proximal segments of the extremities. Fever was not noted. He had received the third dose of trivalent oral poliomyelitis vaccine and diphtheria, pertussis, and tetanus immunizations at 10 months of age. He had not received mumps, measles, or rubella vaccines. He had no past major illnesses. Initial examination revealed an alert but irritable child with a light macular erythematous rash on the trunk, neck, proximal