Tuesday, February 26, 2013

Yersiniosis: Its Neglected But Clinically Significant Effect To Health


Yersiniosis is an acute infectious disease caused by Yersinia enterocolitica is characterized by the symptoms of intoxication, GIT, liver, joints, other organs and systems defeat.

Etiology: Yersinia enterocolitica, gram-negative bacillus


Epidemiology:
·                          Source of infection- ill human and bacterial carrier (transmitter), wild and home animals (rats, dogs, foxes, cats and other);
·                          Mechanism of transmission – fecally-oral, contact-domestic
·                          Way of transmission – alimentary (with infected food, prodacts), contact;
·                          Susceptible organism – all age groups, among children – preschoolers.

Pathogenesis:
1.                        Entering the bacilli to gastrointestinal tract. An entrance gate is a thin bowel (terminal department and appendix)
2.                        Enteral phase: invasion of bacteria in enterocytes, development of local inflammation, diarrhea, enterotoxin secretion.
3.                        Regional lymphadenitis (regional infection).
4.                        Generalization (bacteriemia, toxemia) in severe cases.
5.                        Parenhymatous phasehematogenous distribution of bacteria with forming of the secondary focus (lungs, liver, spleen, bones).
6.                        Immunological response, recovering from disease.
7.                        May be secondary bacteriemia (exacerbations and relapses), because of possible persistansy in lymph nodes.

Diagnostic criteria:
ü     Latent period 3-20 days.
ü     Acute (72.2 %) or gradual (27.8 %) beginning.
ü     Polymorphism of clinical picture.
ü     The symptoms of the Gastro-intestinal tract defeat come forward on a foreground (nausea, stomach-aches, tenderness and grumbling in the ileocecal area, diarrhea as in gastroenteritis, enteritis),
ü     Moderately expressed toxic syndrome, prolonged fever for 1-2 wks.
ü     Rashes for 6-14 days: maculous or maculous-papulous as in measles, nodular erythema, in folds, round joints, lateral surfaces of trunk, chest;
ü     hyperemia of face, hands and feet (“hood”, “gloves”,”socks” symptom)
ü     “strawberry” tongue
ü     arthralgias, rarer arthritis,
ü     hepatomegaly, sometimes parenchymal hepatitis with icterus
ü     mild respirator syndrome (pharyngitis, rhinitis)
ü     Rarely myocarditis, pericarditis,
ü     Splenomegaly (to 20 %),
ü     Lymphoproliferative syndrome (increase of neck, inguinal and other lymph nodes) is insignificantly expressed,
ü     Toxic damage of kidneys (at severe degree)

Classification
Form:
·                     typical
o                           gastro-interstinal,
o                           pseudo appendicitis,
o                           septic (generalized),
o                           hepatic,
o                           nodular erythema,
o                           joint form
·                     atypical (effacedsubclinical)                
Severity:
·                     mild
·                     moderate
·                     severe
Course (duration):   
·   acute:
ü       smooth
ü       relapsed (not smooth, uneven)
·   chronic

Diagnosis example:
·   Yersiniosis, typical joint form, moderate severity, chronic relapsed  duration
·   Yersiniosis, typical gastro-intestinal form, mild severity, acute duration

Yersiniosis peculiarities in infants:
ü     more frequent is gastro-intestinal that generalized (septic) form;
ü     high fever, protracted, expressed intoxication;
ü     dehydration development;
ü     from the first days there is a noticeable lymphoproliferative syndrome, splenomegaly;
ü     frequent respirator syndrome;
ü     seldom develops hepatitis;
·                          arthritis is absent.

Laboratory finding 
·              Complete blood analysis: leucocytosis, neutrophilosis with left shift, eosynophylia, ERS is enlarged.
·              Urinalysis: slight proteinuria, leucocituria, casts uin small amount in case of toxic damage of kidneys.
·              Bacteriological – Yersinia enterocolitica may be found in feces, urine, blood, pus, lymph nodes and pharyngeal mucus.
·              Coprogram: Increasing of red blood sells and leukocytes, mucus.
·              Serologically - increasing of special antibodies 4 times and more in 2-4 wks in paired sera (IHAR 1:200, AR 1:40 – 1:160).

Differential diagnosis with: acute intestinal infections, by viral hepatitis, scarlatina, measles, enterovirus infection, sepsis, pseudotuberculosis, typhoid diseases.

Yersiniosis Differential diagnosis with Pseudotuberculosis

Sign
Yersiniosis
Pseudotuberculosis

beginning
Often subacute
Acute
intoxication
moderateincrease
Severe from the beginning
exanthema
Not often (41 %)
Very often (84 %)
gloves”,  “socks sign
22 %
48 %
conjunctivitisscleritis
12,6 %
30,1 %
Arthralgia 
20,9 %
40,1 %
Abdominal pain
often
Not often
enteritisenterocolitis
A leading symptom
Secondary symptom
Neck lymph nodes enlargement
often
rare
Bacteriology
Yersinia enterocolitica
Yersinia pseudotuberculosis

Treatment

Regimen
ü                  half-bed regimen in mild cases,
ü    bed regimen in moderate cases
ü    straight bed regimen in severe cases
Diet:
ü    Icteric (jaundice) form – N 5
ü    Abdominal (intestinal) form – N 4
ü    Other forms – N 15

1.                Etiological:
·        in mild cases it’s not used;
·        in moderate and severe cases – by chloramphenicol 10-20 mg/kg 4 times per day orally during 6-9 days. If not effective – alternative antibiotics: cefalosporins of the 3rd-4th generation 100-150 mg/kg, aminoglycosides of the 3rd generation.
·        Course of treatment is 7-10 days.
2.                       Pathogenetical:
·  disintoxication oral to all patient and in case of mild dehydration, or parenteral: Rheosorbilact, 0.9% NaCl, 5% glucose (moderate and severe dehydration);
·  Sorbents: enterosgel 0.5-1 g/kg, polysorb (Silix) 100-200 mg/kg per day in 3 doses for 5-7 days

·  antihistamines: claritin, cetirizin, suprastin, pipolphen 1-3 mg/kg per day,

·  corticosteroids 1-3 mg/kg with a short course (in severe cases, in case of myocarditis),
·  Normalisation of the intestinal flora: linex, bifi-form, acidophilus 1-2 caps 2-3 times per day not less than 2 wks;
·  antipyretics: paracethamol 10 mg/kg not more than 5 times per day,
·  NSAIDs in case of arthritis, carditis, nodular erythema (ibuprophen 20 mg/kg per day, aspirin 50-75 mg/kg per day, voltaren 2-3 mg/kg per day, indomethacin 2-3 mg/kg per day (in average doses).

Prophylaxis:
1.     Isolation and treatment of ill person, disinfection.
2.            Correct storage of products, bacteriological control, deratization.
3.            Examination of contact persons from the epidemic focus for 3 wks (measuring the temperature, skin, throat and feces inspection), 1 bacteriological investigation of feces.

Key worlds and phrases: Yersiniosis, polymorphism of complaints, rashes, catharral syndrome, abdominal syndrome, dyspepsia, hepatosplenomegaly, lymphadenopathy, arthritis, hepatitis, myocarditis, nephritis, bronchitis and pneumonia, raspberry tongue, ”gloves”, ”socks”, ”hood”- symptoms.



References:
Main:      
1.      Ambulatory pediatric care/ edited by Robert A. Derchewitz; - 2nd ed. – Lippincot – Raven, 1992. – p. 404-411, P.425-429.
2.      Current therapy in pediatric infections disease – 2/ edited by John D. Nelson, M.D. – B.C. Decker Inc. Toronto, Philadelphia, 1988. – p.74-77, 80-81.
3.      Principles and Practice of Pediatric Infectious Diseases. / Edited by Saran S. Long, Larry K. Pickering, Charles G. Prober, PhiladelphiaPa: Churchill Livingstone; 1997. – 1921 p.

Additional:
1.                         Cleary TG: Yersinia. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia: WB Saunders; 2000: 857-859.
2.                         Pickering L, ed: Yersinia enterocolitica and Yersinia pseudotuberculosis infections. In: Red Book: Report of the Committee on Infectious Diseases. 25th ed. Elk Grove VillageIllAmerican Academy of Pediatrics; 2000: 642-643.
3.                         Textbook of Pediatric Nursing.  Dorothy R. Marlow; R. N., Ed. D. –London, 1989.-661p.
4.                         Pediatrics ( 2nd edition, editor – Paul H.Dworkin, M.D.) – 1992. – 550 pp.
5.                         Behrman R.E., Kliegman R.M., Jenson H.B. Nelson nextbook of Pediatrics. - Saunders. - 2004. - 2618 p.
6.                         Castaneda C. Effects of Saccharomyces boulardii in children with Chronic Diarrhoea, Especially Due to Giardiasis // Revista Mexicana de Puericultura y Pediatria. - 1995. - V. 12. - P. 1462-1464.
7.                         Guidelines for control of shigellosis, icluding epidemics due to Shigella type 1/-World Health Organisation, 2005.
8.                         Implementing the New Recommendation on the Clinical Management of Diarrhoea. - World Health Organisation, 2006.
9.                         Klein J.D., Zaoutis T.E. Pediatric Infectious Disease Secrets. - Philedelphia: Hanley & Belfus Inc, 2003. - P. 142.

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