A case of yersinia infection fron 1 the Middle East : Case report and literature review

The authors report the first case of yersinia infection of the cecum, appendix and mesenteric lymph nodes from the Middle East, together with a literature review on yersiniosis. The case is unique in that the cecum was affected while the terminal ileum was free from disease.

probably the first report o( cecal ye rsinia infection in the literature.

C A SE PRESENT ATION
A '35-yea r-tild Kuwnni maleprl'sented with a 24 h h1:,tory of fever, nght-siJ ed abdom inal pai n , and a sing le attack of vomiting.On exa mmation, the patient looked il l and frh r ile (temperature 38.5°C).T he abdomen was very render and guarded in the right iliac fossa, whi le the rest of the abdomen was normal wn h no orga nomegaly.Ful l blood co un t showed a normal hemog lobin conccnt n111on ( 150 g/L) mid leukocytrn,is ( l 4.6xl0 9 /L ).
A clin1Lal diagnosis o( acute appl•nJ i-c1t1s was made and surgery 1111t1a1ed. At laparotomy there was a large, indurated, angry-looking mass involvi ng rhe cecum, the ha:,e of the appendix, and the ileocecal region.T he ilcoLecal region conrained mult iple large lymph mx.lcs matteJ rngethcr and adherent to the Lecum.The term inal ileum ,irpeared free from disease.Lymphoma was suspected (a nm un<.:om mon um<li-11011 considering 1 he authors' area and the age o( the patient ), and therefore cu rat IVl' ri gh t hem 1uilectomy with deot r,insverse anastomo~•~ was per- formed.Histopathology of th e specimen revealed ye rsinios is.
During the postoperative perio<l the patient develope<l fever and d ia rrhea wh ic h responded we 11 to ora I tetracycl ine.
Repeated stool and blood culture~ fa iled to identify t he organ ism.Serology for Yersinia species cou ld not be done in the authors' laboratories.
At three months, one year and two years of fo llow-up, the pat ient remai ns well and symptom free.

HISTOLOGICAL FINDINGS
Pathological examinat ion of the ileocecal valve, cecum and appendix s howed acute transmura l in flam mation.T he inflammamry infiltrate was composed of neutrophi ls, plasma cells, eosinoph ils :1nd a few macrophages present diffusely with in the wa ll.Focal mucosa l ulceration was p rese n r.Numerous epit he l ioid granulomas were present in the mucosa, submuco~a and subserosa, composed of necrot ic core packed with neutrophils and bordered by pallisaded epithelinid cells (Figure J ).These features are diagnostic of ycrsinia infection ( 1,4 ).
The mcsentcric lymph nodes examined revealed similar granu lomas composed of centra l necrosb and a peripheral pall isade of cpithclioid cells.
No giant cells were seen.The lymph node sinuses contai neJ a milJ h istiocytic infiltrate (Figure 2 ).
T he terminal ileum showeJ no sign ificant histological abnormality.

DISCUSSION
Human infection with Yersinia species i~ ca used by Yersinia enterocolitica and Yersinia /Jseudotuberculosis.T ransmission to h uma ns has usually heen traced w contact with an infec t ed anima l o r with con taminarcJ fooJ anJ water (5).Refrigeration increases the risk of infection, as the orga n i,m flourishes at low tcmperawrc:,.
These organisms arc known w cause acu te terminal ileitis a nd mcscmeric lymphadcnitis.T hey have heen inc riminated as a cause of nonspecific right lower abdominal pain .Other rare manifestations are po lyarth ri tis, e rythema nodosum, septicemia a nd metastatic abscess (6).
Yersiniosis is a self-limiting disease which usual ly responds very well to tetracycline, aminoglycosidcs, cotrimoxazole or chloramphenicol ( 4).
T here is a high incidence of yersinia infection in Belgium and other parts of Europe.In Brita in and Ireland yersinia was not generally considered LO be a common cause of gastroenteritis and abdominal pain (2).H owever, a recent report from Ireland showcJ 3 1 % of patients with acute appendic itis anJ 12% with nonspecific right il iac fossa pain to have yersinia infection on sequentia l serology (ie, blood s;:imples on admission ::md seven days later) (7).
The diagnosis of yersinia infection can he confirmed by stool cultu res and serological stud ics.For better ident ification of cases, it was suggested that both acute and conva lescenc phase scrum serology needed w be Jone, as the yield after acute phase serology alone was very low ( 7% in acute appendicitis and I% 111 nonspec ific abdominal pain) (7) .
Yersinia species h ave hecn rnrcly incrim inated as the primary pathogen in acute appendicitis ,i nd tox ic megacolon (8,9).The cn,e reported in this paper is probably the first case in the li terature of pathologicall y proven yers inia infection of the cecum.In chi~ case, yersinia affected the mesen reric lymph nod es, cecum and append ix, with prcbervation of the termin,11 ileum.A subp ic ion of (right hemicolcctomy) for thb patient.If yersiniosis had been suspected, th e pa tient prohahly would have been managed conservat ively.
In the Middle East, infection with Yersinia species has n ot hcen reported.T he present case is the first report from that part of the world of ye rs ini a infection of the cecu m, mesenteric lymph nodes and appendi x.The autho rs feel that the disease o ught to be more com-

Yersinia infection from the Middle East mon
in th e Middle East, a~ the consumption of refri gerated food is high, an<l a large percentage of food is imported from Europe.More awareness of the cond ition is required by cli nic ians practising in the area, especially when dealing with cases of gm,tmenteritis and nonspec ific right iliac fossa pain.Increased availahilily of serological tests fo r ycrsinia in local lahorntorics b requi red.7.Attwood SEA, Mea ly K, Ca ffrrk ey CAN J GASTROENTEROL Vm 5 No 2 MARt •11/Al'RII 199 1