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Don't forget to rule out the unusual... Dr. M H Jaffer. CASE PRESENTATIONS. Patient 1. 32 year old male Presents with symptoms of recurrent GIT disturbance with right iliac fossa pains for the last 3 years on and off -currently a bit of diarrhoea, no vomiting
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Don't forget to rule out the unusual... Dr. M H Jaffer CASE PRESENTATIONS
Patient 1 • 32 year old male • Presents with symptoms of recurrent GIT disturbance with right iliac fossa pains for the last 3 years on and off -currently a bit of diarrhoea, no vomiting • Used numerous antibiotics with only temporary relief • No bleeding in stool
continued... • Stool microscopy showed no significant findings most of the times • Already has appendicectomy during the start of the problem • OGD done a while back- no significant finds...a bit of GERD
pt. 1.... • o/e the patient has a fair general condition, afebrile • Abdomen was soft, no masses palpable, tender over the right iliac fossa, rovsing, psoas and obturator signs negative • Also found some singular, enlarged lymph nodes in the right inguinal region. Non tender, not matted, mobile. • Rest of systems normal
pt. 1 • On probing into the history with more detail: • Eats regular food, nothing out of the ordinary • No history of allergies • Pain not worse at any specific times like postprandially... • Discovered however that he changed his location of residence about 2-3 months before the symtoms began....and there were rats in the new residence...
pt. 1 • Repeat stool microscopy normal-not willing for LN biopsy • Treated with tetracyclin first, and he came to stop the meds due to severe GI side effects • Changed the meds to doxicyclin and he improved considerably-advised to change residence to prevent re-infection as well as asked to improve on hygiene(already did) • Not seen the patient again • Most likely diagnosis: Yessirnia enterocolitica infection AKA yessirniosis!!
discussion... • What is Yessirniosis? • How is it spread? How its proven... • What is the recommended treatment? • A bit of epidemiology of the same... • When should one think of it?? • Lessons learnt: Proper history taking...consider rare things as well as the common ones! • Not always face value...
Yessirniosis • Infection with Y. Entercolitica/ Y. Pseudotubeculosis- Gram -ve rod shaped bacteria • Uncommon in the states but more common in the less developed countries • Yessirnia species have an association with rodents....most commonly the Y. Pestis that causes bubonic plague.
Transmission • Primary yessirniosis- Food transmission- especially meat or pork products. It's fridge or freezer stable like listeria monocytogenes • It may also be transmitted by infective agents that may be carrying it (infected animals-dogs, cats, rodents) • Also infected person to person transmission (contact) and by blood transfusion
pathophysiology • Y. enterocolitica adheres to epithelial cells and mucus, and heat-stable enterotoxins are produced, which play a role in the development of watery diarrhea. Another cytotoxin then directly injures the distal small bowel and large bowel, producing the characteristic bloody or mucous diarrhea. An enterocolitis develops and usually persists 5–14 days and is seen most commonly in the younger age groups. A pseudoappendicular syndrome owing to mesenteric adenitis and/or terminal ileitis is seen more commonly in the older child or young adult. Extraintestinal manifestations include pharyngitis, suppurative lymphadenitis, pyomyositis, osteomyelitis, abscess, UTI, pneumonia, endocarditis, meningitis, peritonitis, panophthalmitis, conjunctivitis, and septic arthritis
Detection • Stool (most Labs don't test for it) • Blood • Lymph node • Food tests
Epidemiology • World stat- 1/100,000 people have it • But considered that more prevalent in the less developed countries • No relevant studies on this and data presented is extrapolated from the studies in developed countries
Treatment • Uncomplicated cases of diarrhea due to Y. enterocolitica usually resolve on their own without antibiotic treatment. However, in more severe or complicated infections, antibiotics such as aminoglycosides, doxycycline, trimethoprim-sulfamethoxazole, or fluoroquinolones may be useful. .
Prevention Prevention- Hygiene, Detection and treatment, education 1. Avoid eating raw or undercooked pork. 2. Consume only pasteurized milk or milk products. Dispose of animal feces in a sanitary manner.
3. Wash hands with soap and water before eating and preparing food, after contact with animals, and after handling raw meat. • 4. Prevent cross-contamination in the kitchen: -Use separate cutting boards for meat and other foods. -Carefully clean all cutting boards, counter-tops, and utensils with soap and hot water after preparing raw meat.
Complications and sequelae • Complications and sequelae of Yersiniosis from the Diseases Database include: • · ··Pyrexia of unknown origin • · ··Abdominal mass • · ··Reactive arthropathy (1-6 months)-2-3% • · ··Erythema nodosum (resolve in a month) • · ··Abdominal pain • · ··Diarrhoea
Lessons Learnt • Thorough history taking • Consider as many possibilities as possible in the Ddx • When meds dont work dont just continue with the same outlook • Probe into the cause of infection, not just the treatment!!
