An 88–year–old male presented with weakness. He had non–bloody diarrhea one week prior which had since resolved. He had associated anorexia and weakness. His weakness persisted and he developed a right–sided dull pain. He denied any sick contacts or ingestion of uncooked food. ROS was positive only for generalized weakness. Medical history includes hypertension and diverticulosis. Exam revealed a well–nourished and well–kept elderly man in no distress. He had diminished breath sounds and crackles in his right lower lung field. He had right upper quadrant tenderness. Labs were significant for an elevated creatinine of 2.5 mg/dL, hemoglobin of 11.5 g/dL and a wbc count of 20 × 103/mL. A chest radiograph showed an elevated right hemi–diaphragm. A CT scan revealed a cyst–like mass occupying the right hepatic lobe of the liver. An MRI in 2008 was notable only for a hemangioma. The patient developed a fever of 102[cir]F on day 1. Blood cultures on day 2 revealed Gram Negative, Lactose Negative, Oxidase Negative Rods consistent with Yersinia Enterocolitica (YE). CT–guided liver aspirate also grew YE. The patient was treated with Ciprofloxacin 500mg intravenous twice a day for a total of three weeks. He remained afebrile and all further cultures remained negative.
Yersinia is a reportable disease and approximately 17,000 cases of Y.Enterocolitica are reported yearly in the United States. The majority of these cases present as diarrhea, fever, and abdominal pain which almost invariably self–resolve. YE very rarely causes septicemia and/or hepatic and splenic abscesses. YE is a zoonotic disease often acquired through poorly cooked pork although it has been acquired through a variety of meat and vegetable products. Risk factors include extremes of age, hemochromatosis, or chronic hemolytic conditions. It is also one of the most common and deadliest infections in stored blood and may be transmitted through blood tranfusions.
Yersinia Enterocolitica must be considered in any presentation of gastroenteritis for appropriate management. YE is infamous for causing pseudo–appendicitis and up to 10% of patients undergo an unnecessary appendectomy. Because Yersinia is a siderophillic organism, patients with hemochromatosis, G6PD deficiency, thalassemia, sickle cell, and other chronic hemolytic conditions must carry a higher–index of suspicion for Yersinia infection. Some sources advise this patient population to avoid pork secondary to their predisposition. Chronic sequela involves reactive arthritis, myocarditis, glomerulonephritis, and liver failure. Treatment is only recommended for severe disease defined by septicemia or abscess formation but may be considered for milder disease in iron overloaded immunocompromised patients. While treatment successfully diminishes bacterial shedding, human to human transmission is rare. Treatment of severe disease includes a third generation cephalosporin combined with Gentamicin. Ciprofloxacin may replace ceftriaxone if susceptible.
Figure 1Chest radiograph upon admission showing a elevated right hemi–diaphragm.
Figure 2CT upon admission showing a large hepatic mass.