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Yersinia enterocolitica inguinal lymphadenitis
DIAGN MICROBIALINFECT DIS 1986;5:265-268
265
CASE REPORT
Yersinia enterocofitica Inguinal L y m p h a d e n i t i s Robert S. Zimmerman and John D. Hamilton
Inguinal lymphadenitis is associated with a well-defined group of etiologic agents including many sexually transmitted diseases and nonvenereal agents including Yersinia pestis (bubonic plague). We report herein the first case of a second Yersinia species--Yersinia enterocolitica-presenting like bubonic plague with bilateral inguinal lymphudenitis.
INTRODUCTION Inguinal lymphadenitis is a common clinical presentation associated with a welldefined group of etiologic agents. Most commonly, inguinal lymphadenitis is associated with sexually transmitted diseases including gonorrhea, primary syphilis, herpes genitalis, chancroid, and lymphogranuloma venereum. Nonveneral infections associated with buboes include cat scratch disease, bubonic plague, tularemia, typical and atypical mycobacteria, streptococci, and staphylococci (Rein, 1979). We report herein the first case of bilateral inguinal lymphadenitis caused by Yersinia enterocolitica. CASE REPORT
A 67-yr-old black man who was an insulin-dependent diabetic was admitted to the Durham Veterans Administration Medical Center for evaluation of new onset bilateral lymphadenitis. The patient was well until 1973 when he developed right-sided weakness secondary to a left middle cerebral artery vascular accident. He was noted to have an elevated blood glucose at that time and was started on oral hypoglycemic medications. The patient did well with resolution of his right-sided weakness until 1977 when he developed ulcers on his right foot secondary to peripheral vascular disease leading to osteomyelitis. Despite intensive antibiotic therapy the patient ultimately required a below the knee amputation of his right leg in 1978. He was started on insulin during that hospitalization. The patient did well subsequently until June 1983 when he developed a tender mass in the left inguinal area. One week later he developed a tender mass in the right inguinal area. He was seen by his local physician and told that he had a hernia. Three days later he developed a purulent drainage from the left inguinal mass, fever, chills, and night sweats. He was treated with erythromycin 500 mg p.o. QID. He
From the Department of Medicine, Durham Veterans Administration Medical Center and Duke University Medical Center, Durham, NC. Address reprint requests to: John D. Hamilton, M.D., Veterans Administration Medical Center, 508 Fulton Street, Durham, NC 27705. Received June 17, 1985; revised and accepted March 14, 1986.
© 1966 Elsevier Science Publishing Co., Inc.
52 Vanderbilt Avenue, New York, NY 10017
0732-8893/86/$03.50
266
R.S. Zimmerman and J.D. Hamilton
sought a second medical opinion from the Durham Veterans Administration Medical Center 3 days later and was admitted for treatment and evaluation. On physical examination his blood pressure was 140/70, pulse 72, respiration 16, and he was afebrile. He had a right below the knee amputation, with a well healed nontender stump. Bilateral 3 x 3 cm tender inguinal nodes were present with pus draining from the left node and erythema and induration overlying the right node (Figure 1). Rectal examination was notable for large external hemorrhoids. Neurologic examination was notable only for decreased pin prick sensation in the left foot. Pulses were normal except for absent dorsalis pedis and posterior tibial pulses in the left foot. The remainder of his physical examination was normal. Laboratory data included a hematocrit of 39.1%; white cell count of 15,700 with 69% neutrophils, 22% lymphocytes, 8% monocytes, and 2% eosinophils. The platelet count was 254,000. Urinalysis was normal. Serum glucose was 130 mg/100 ml, and the remainder of his blood chemistries were not remarkable. His serologic test for syphilis was negative. The patient was admitted and cultures were obtained from the left inguinal node by needle aspiration. Gram stain of the aspirate revealed numerous polymorphonuclear leukocytes and few gram-negative rods. The patient was initially treated with intravenous nafcillin (1 g) every 6 hr. Despite this therapy the patient was febrile to 100°F daily for the first 3 days of his hospitalization. On day three of his hospitalization culture of the left inguinal node aspirate grew Yersinia enterocolitica and one colony of Staphylococcus epidermidis. The Yersinia was isolated on blood and MacConkey's agar, confirmed to be an enteric gramnegative rod and specifically identified as Yersinia enterocolitica by API strip. Sensitivity testing was done for aerobic, gram-negative rods and revealed sensitivity to gentamicin, tobramycin, amikacin, chloramphenicol, tetracycline, and trimethoprim/sulfamethoxozole. The organism was resistant to cephalosporin, ampicillin, and carbenicillin. No tests for erythromycin sensitivity were performed. The patient was treated with 320 mg trimethoprim/1600 mg sulfamethoxazole twice a day for 35 days. Three days after initiation of trimethoprim/sulfamethoxazole therapy the patient's fever resolved. His white blood cell count was 10,000 2 days after the antibiotic change and was 7,800 12 days after trimethoprim/sulfamethoxazole therapy was initiated. His drainage and induration resolved and a follow-up culture was negative for Yersinia. A barium enema and abdominal computed tomography scan were obtained to rule out the possibility of an intraabdominal abscess and were entirely normal. The patient had no evidence of relapse on I month and 6 month follow-ups in the clinic. This case represents the first report of Yersinia enterocolitica infection presenting as bilateral buboes. Yersinia enterocolitica has been more commonly associated with other presentations including gastroenteritis, erythema nodosum, arthritis, myocarditis, fever, and mesenteric lymphadenitis (Bottone, 1977; Arvastson et al., 1971). This patient had none of these clinical signs except fever. More common causes of inguinal lymphadenitis include gonorrhea, syphilis, herpes, genitalis, chancroid, lymphogranuloma venereum, cat scratch fever, bubonic plague, typical and atypical mycobacteria, streptococci, and staphylococci (Rein, 1979). It is interesting that this patient's clinical presentation was similar to that of patients presenting with Yersinia pestis in causing bilateral buboes (Poland, 1983). The patient's other systemic symptoms were much less severe than would be anticipated with untreated Yersinia pestis and this patient had no travel history to endemic areas of Yersinia pestis. How this patient developed Yersinia enterocolitica inguinal lymphadenitis is purely speculative. The patient is a diabetic who injected himself in the legs. It is
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possible that he c o n t a m i n a t e d an i n s u l i n syringe w i t h enteric pathogens resulting in direct i n o c u l a t i o n into inguinal l y m p h a t i c drainage sites. The patient h a d no abd o m i n a l pain, no a b d o m i n a l abscess, no diarrhea, a n d no arthritis. Yersinia enterocolitica s h o u l d be a d d e d to the differential diagnosis of bilateral buboes. REFERENCES Arvastson B, Damgaard K, Winblud S (1971) Clinical symptoms of infection with Yersinia enterocolitica. S c a n d ] Infect Dis 3:37. Bottone EJ (1977) Yersinia enterocolitica: a panoramic view of a charismatic microorganism. CRC Crit Rev Microbiol 5:211. Poland JD (1983) Plague. In Infectious Diseases. Ed., PD Hoeprich. Philadelphia: Harper and Row, pp 1227-1240. Rein MF (1979) Inguinal adenopathy. In Principles and Practices of Infectious Diseases. Eds., GL Mandell, RG Douglas, JE Bennett. New York: John Wiley & Sons, pp 1002-1008.
265
CASE REPORT
Yersinia enterocofitica Inguinal L y m p h a d e n i t i s Robert S. Zimmerman and John D. Hamilton
Inguinal lymphadenitis is associated with a well-defined group of etiologic agents including many sexually transmitted diseases and nonvenereal agents including Yersinia pestis (bubonic plague). We report herein the first case of a second Yersinia species--Yersinia enterocolitica-presenting like bubonic plague with bilateral inguinal lymphudenitis.
INTRODUCTION Inguinal lymphadenitis is a common clinical presentation associated with a welldefined group of etiologic agents. Most commonly, inguinal lymphadenitis is associated with sexually transmitted diseases including gonorrhea, primary syphilis, herpes genitalis, chancroid, and lymphogranuloma venereum. Nonveneral infections associated with buboes include cat scratch disease, bubonic plague, tularemia, typical and atypical mycobacteria, streptococci, and staphylococci (Rein, 1979). We report herein the first case of bilateral inguinal lymphadenitis caused by Yersinia enterocolitica. CASE REPORT
A 67-yr-old black man who was an insulin-dependent diabetic was admitted to the Durham Veterans Administration Medical Center for evaluation of new onset bilateral lymphadenitis. The patient was well until 1973 when he developed right-sided weakness secondary to a left middle cerebral artery vascular accident. He was noted to have an elevated blood glucose at that time and was started on oral hypoglycemic medications. The patient did well with resolution of his right-sided weakness until 1977 when he developed ulcers on his right foot secondary to peripheral vascular disease leading to osteomyelitis. Despite intensive antibiotic therapy the patient ultimately required a below the knee amputation of his right leg in 1978. He was started on insulin during that hospitalization. The patient did well subsequently until June 1983 when he developed a tender mass in the left inguinal area. One week later he developed a tender mass in the right inguinal area. He was seen by his local physician and told that he had a hernia. Three days later he developed a purulent drainage from the left inguinal mass, fever, chills, and night sweats. He was treated with erythromycin 500 mg p.o. QID. He
From the Department of Medicine, Durham Veterans Administration Medical Center and Duke University Medical Center, Durham, NC. Address reprint requests to: John D. Hamilton, M.D., Veterans Administration Medical Center, 508 Fulton Street, Durham, NC 27705. Received June 17, 1985; revised and accepted March 14, 1986.
© 1966 Elsevier Science Publishing Co., Inc.
52 Vanderbilt Avenue, New York, NY 10017
0732-8893/86/$03.50
266
R.S. Zimmerman and J.D. Hamilton
sought a second medical opinion from the Durham Veterans Administration Medical Center 3 days later and was admitted for treatment and evaluation. On physical examination his blood pressure was 140/70, pulse 72, respiration 16, and he was afebrile. He had a right below the knee amputation, with a well healed nontender stump. Bilateral 3 x 3 cm tender inguinal nodes were present with pus draining from the left node and erythema and induration overlying the right node (Figure 1). Rectal examination was notable for large external hemorrhoids. Neurologic examination was notable only for decreased pin prick sensation in the left foot. Pulses were normal except for absent dorsalis pedis and posterior tibial pulses in the left foot. The remainder of his physical examination was normal. Laboratory data included a hematocrit of 39.1%; white cell count of 15,700 with 69% neutrophils, 22% lymphocytes, 8% monocytes, and 2% eosinophils. The platelet count was 254,000. Urinalysis was normal. Serum glucose was 130 mg/100 ml, and the remainder of his blood chemistries were not remarkable. His serologic test for syphilis was negative. The patient was admitted and cultures were obtained from the left inguinal node by needle aspiration. Gram stain of the aspirate revealed numerous polymorphonuclear leukocytes and few gram-negative rods. The patient was initially treated with intravenous nafcillin (1 g) every 6 hr. Despite this therapy the patient was febrile to 100°F daily for the first 3 days of his hospitalization. On day three of his hospitalization culture of the left inguinal node aspirate grew Yersinia enterocolitica and one colony of Staphylococcus epidermidis. The Yersinia was isolated on blood and MacConkey's agar, confirmed to be an enteric gramnegative rod and specifically identified as Yersinia enterocolitica by API strip. Sensitivity testing was done for aerobic, gram-negative rods and revealed sensitivity to gentamicin, tobramycin, amikacin, chloramphenicol, tetracycline, and trimethoprim/sulfamethoxozole. The organism was resistant to cephalosporin, ampicillin, and carbenicillin. No tests for erythromycin sensitivity were performed. The patient was treated with 320 mg trimethoprim/1600 mg sulfamethoxazole twice a day for 35 days. Three days after initiation of trimethoprim/sulfamethoxazole therapy the patient's fever resolved. His white blood cell count was 10,000 2 days after the antibiotic change and was 7,800 12 days after trimethoprim/sulfamethoxazole therapy was initiated. His drainage and induration resolved and a follow-up culture was negative for Yersinia. A barium enema and abdominal computed tomography scan were obtained to rule out the possibility of an intraabdominal abscess and were entirely normal. The patient had no evidence of relapse on I month and 6 month follow-ups in the clinic. This case represents the first report of Yersinia enterocolitica infection presenting as bilateral buboes. Yersinia enterocolitica has been more commonly associated with other presentations including gastroenteritis, erythema nodosum, arthritis, myocarditis, fever, and mesenteric lymphadenitis (Bottone, 1977; Arvastson et al., 1971). This patient had none of these clinical signs except fever. More common causes of inguinal lymphadenitis include gonorrhea, syphilis, herpes, genitalis, chancroid, lymphogranuloma venereum, cat scratch fever, bubonic plague, typical and atypical mycobacteria, streptococci, and staphylococci (Rein, 1979). It is interesting that this patient's clinical presentation was similar to that of patients presenting with Yersinia pestis in causing bilateral buboes (Poland, 1983). The patient's other systemic symptoms were much less severe than would be anticipated with untreated Yersinia pestis and this patient had no travel history to endemic areas of Yersinia pestis. How this patient developed Yersinia enterocolitica inguinal lymphadenitis is purely speculative. The patient is a diabetic who injected himself in the legs. It is
J~
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t~
r-
p~
L
I
L~
~o
CD
~D
26a
R.S. Z i m m e r m a n and J.D. H a m i l t o n
possible that he c o n t a m i n a t e d an i n s u l i n syringe w i t h enteric pathogens resulting in direct i n o c u l a t i o n into inguinal l y m p h a t i c drainage sites. The patient h a d no abd o m i n a l pain, no a b d o m i n a l abscess, no diarrhea, a n d no arthritis. Yersinia enterocolitica s h o u l d be a d d e d to the differential diagnosis of bilateral buboes. REFERENCES Arvastson B, Damgaard K, Winblud S (1971) Clinical symptoms of infection with Yersinia enterocolitica. S c a n d ] Infect Dis 3:37. Bottone EJ (1977) Yersinia enterocolitica: a panoramic view of a charismatic microorganism. CRC Crit Rev Microbiol 5:211. Poland JD (1983) Plague. In Infectious Diseases. Ed., PD Hoeprich. Philadelphia: Harper and Row, pp 1227-1240. Rein MF (1979) Inguinal adenopathy. In Principles and Practices of Infectious Diseases. Eds., GL Mandell, RG Douglas, JE Bennett. New York: John Wiley & Sons, pp 1002-1008.