Liver abscess due to Yersinia enterocolitica L. MANTSE, MD; J. WEST, MD; H.H. COSMAN, MD, FRCP[C]; J.E. MULLENS, MD, MS. FRCS[C]
Yersinia enterocolitica is a gram- pathy the only physical abnormality negative, non-spore-forming bacillus noted was slight enlargement of the that has been identified as a pathogen liver, to 18 cm in the midclavicular line. The hemoglobin concentration was in animals and in recent years has g/dL and the leukocyte count 10.7 been recognized as an uncommon 10.7 x 109/L with 92% neutrophils. cause of human disease.1 In humans Concentrations of serum constituents Y. enterocolitica may cause mesen- were as follows: bilirubin 5.3 mg/dL, teric lymphadenitis or appendicitis, alkaline phosphatase 939 lU/L, serum and sometimes it causes a form of glutamic oxaloacetic transaminase 180 terminal ileitis that must be distin- lU/L and albumin 2.4 g/dL. The blood guished from Crohn's disease.1 Poly- urea nitrogen concentration was 27 arthritis and erythema nodosum have mg/dL and the blood glucose conalso been described in humans infec- centration 428 mg/dL. Y. enterocolitica sensitive to gentated with this organism.1 Recently Y. enterocolitica has been identified as micin and trimethoprim was cultured the blood. a cause of septicemia and liver ab- from 60 mg q8h, was adGentamicin, scess. We describe the case of a man ministered intramuscularly and investiwith diabetes who presented with gations of liver function were consepticemia and liver abscess due to ducted. An intravenous cholangiogram Y. enterocolitica.3 showed no function of the gallbladder and did not demonstrate the biliary tree. Case report Ultrasonography, however, recorded a gallbladder and collecting sysA 64-year-old man who had had normal and endoscopic retrograde cholantem, diabetes mellitus for 16 years presented giopancreatography showed a to hospital with a 3-week history of normal gallbladder (ERCP) bile ducts. A and anorexia, intermittent fever and rigors, gallium-67 scan disclosed an area of sweating and a weight loss of 14 kg. uptake and a probable abscess in He required 30 U of NPH (iso- high the liver; a technetiumthe centre phane) insulin per day; his diabetes 99m scan of space-occupying showed was poorly controlled primarily be- lesion in the centre ofa the liver extendcause of poor dietary compliance. Six ing into the left lobe. vision his this admission months before A diagnosis of liver abscess was had become blurred and proliferative made. Laparotomy revealed two liver diabetic retinopathy was diagnosed. He abscesses, each approximately 4 cm in had had no other significant illness. No other abnormalities were He was moderately obese. His tem- diameter. in the abdominal viscera. The detected perature was 380C and spiked to 41 0C. abscesses contained a firm, cheesy maAside from proliferative diabetic retino- terial; necrotic liver metastases were considered as a diagnosis. Y. enteroFrom the departments of medicine and colitica was cultured from abscess masurgery, Ottawa Civic Hospital and terial, and specimens from biopsies of University of Ottawa the abscesses showed areas of acute Reprint requests to: Dr. J.E. Mullens, chronic inflammatory change with and Department of surgery, Ottawa Civic fibrosis, as well as necrosis with abscess Hospital, 1053 Carling Ave., Ottawa, formation. Ont. K1Y 4E9 922 CMA JOURNAL/OCTOBER 21, 1978/VOL. 119
The patient responded well to gentamicin therapy and was discharged taking a 6-week course of trimethoprim.
Discussion Y. enterocolitica, a gram-negative coccobacillus, is urease-positive, oxidase-negative and motile only at 250C.4 It was previously known as Bacterium enterocoliticum and Pasturella pseudotuberculosis type B. The organism will grow readily on standard media when specimens are taken from humans or animals.5'6 Nilehn and Sjostrom7 have isolated the organism from the gastrointestinal tract of 4% to 6% of patients with acute appendicitis. The isolation rate in controls was 0.1%. Septicemia caused by Y. enterocoutica is rare.8'9 At the time this report was written only two other proven cases of septicemia due to this organism had been described in Canada.10"1 Recently Reinicke and Korner3 reviewed the world literature and were able to find only 25 such cases. Y. enterocolitica usually produces a self-limiting infection confined to the gastrointestinal tract, but it can cause a life-threatening situation, especially in patients with chronic diseases such as diabetes mellitus, cirrhosis of the liver, leukemia or alcoholism, and in those receiving immunosuppressive therapy.'2 In the six previously reported cases of septicemia caused by Y. enterocoutica with associated liver abscess all six patients had either diabetes or cirrhosis of the liver and died of the infection. Only one patient with Y. enterocolitica liver abscess has sur-
vived, and this patient did not have associated septicemia.13 Our patient is the only one to have Y. enterocolitica septicemia and liver abscess and to survive.
other gram-negative bacteria. J Appi Bacteriol 24: 252, 1961 6. Hxssio A, KARRER J, PUSTERLA F: Ueber Pseudotuberkulose beim Menschen. Schweiz Med Wochenselir 79: 971, 1949 7. NILEHN B, SJOSTROM B: Studies on Yersinia enterocolitica. A cta Patliol
References
Microbiol Scand 206 (suppD: 8, 1969
1. LEINO R, KALLIOMAKI JL: Yersiniosis as an internal disease. Ann intern Med 81: 458, 1974 2. VANTRAPPEN G, PONETTE E, GEBOES K, et al: Yersinia enteritis and enterocolitis: gastroenterological aspects. Gastroenterology 72: 220, 1977 3. REINICKE V, KORNER B: Fulminant septicemia caused by Yersinia enterocolitica. Scand J infect Dis 9: 249, 1977 4. SCHLEIFSTEIN J, COLEMAN M: Bacterium enterocoliticum, annual report, division of laboratory research, New York State Department of Health, 1943, p 56 5. DICKINSON AB, MocQuo'r G: Studies on the bacterial flora of the alimentary tract of pigs. I. Enterobacteriacea and
BOOKS continued from page 886 PROCEEDINGS OF THE 1977 ASPIRIN FOUNDATION SYMPOSIUM. Proceedings of a Symposium Sponsored by the Aspirin Foundation and held at the Royal College of Surgeons, London, on 1 November 1977. Edited by John S. Goodall. 36 pp. Published as Volume 70, Supplement *7, 1977 of Proceedings of the Royal Society of Medicine. The Royal Society of Medicine, London for the Aspirin Foundation, London, 1977. Price not stated, paperbound. ISSN 0-308-2520 PSYCHOLOGICAL DISORDERS OF CHILDREN. A Handbook for Primary Care Physicians. Mark A. Stewart and Ann Gath. 167 pp. lIlust. The Williams & Wilkins Company, Baltimore; Burns & MacEachern Limited, Don Mills, 1978. $11.95, paperbound. ISBN 0-683-97179-9 PSYCHOPHARMACOLOGY FOR PRIMARY CARE PHYSICIANS. Charles L. Bowden and Martin B. Giffen. 91 pp. Illust. The Williams & Wilkins Company, Baltimore; Burns & MacEachern Limited, Don Mills, 1978. $10.75, paperbound. ISBN 0-683 010050-0 ROENTGENOLOGIC ANATOMY OF THE LUNG. Hideaki Yamashita. 389 pp. Illust. Igaku-Shoin, Tokyo; Igaku-Shoin, New York, 1978. $79.50. ISBN 0-89640028-X SYNOPSIS OF CLINICAL PULMONARY DISEASE. 2nd ed. Edited by Roger S. Mitchell. 352 pp. IlIust. The C.V. Mosby Company, Saint Louis, 1978. $12, paper. bound. ISBN 0-8016-3430-X THE YEAR BOOK OF DRUG THERAPY 1978. Edited by Daniel L. Azarnoff. 448 pp. IlIust. Year Book Medical Publishers, Inc., Chicago, 1978. $28.05. ISBN 0-81510387.5
continued on page 928
8. CHESSUM B, FRENGLEY JD, FLECK DG, et al: Case of septicaemia due to Yersinia enterocolitica. Br Med J
3: 466, 1971 9. MOLLARET HH, OMLAND T, HENRIKSEN SD, et al: Les septic.mies humaines . "Yersinia enterocolitica". A
propos de dix-sept cas r.cents. Noiiv Presse Med 79: 345, 1971 10. ABRAMOVITCH H, BUTAS CA: Septicemia due to Yersina enterocolitica.
Can Med Assoc J 109: 1112, 1973 11. NARASJMHAN SL, SCHIEVEN BC, CAMPSALL EWR: Septicemia caused by Yer-
sinia enterocolitica. Can Med Assoc J 118: 682, 1978 12. RABSON AR, KOORNHOF HF, NOrMAN J, et al: Hepatosplenic abscesses due
to Yersinia enterocolitica. Br Med J 4: 341, 1972 13. BLOQUIAUX W: Multiple Leverabscessen
door
Yersinia
enterocolitica.
Tijdschr Gastroenterol 11: 578, 1968
The year was 64 A.D.
Emperor Nero abused his stomach just as he abused his city Burningly And there w.a. no DiovoL -
N
*. .uv Diov l with Fresh Fruit Flavour S. P*fl.iOfltZj
D
the patient whose stomach's afire.
CCPP
Fresh Fruit FlavourDiovol antacid/antiflatulentsuspension contains perS ml 200mg aluminum hydrosicle equivalent to dried gel. 200mg magnesium hydroxide. 25mg simethicone Full prescribing intormation available on request
CMA JOURNAL/OCTOBER 21, 1978/VOL. 119 923
Yersinia enterocolitica is a gram- pathy the only physical abnormality negative, non-spore-forming bacillus noted was slight enlargement of the that has been identified as a pathogen liver, to 18 cm in the midclavicular line. The hemoglobin concentration was in animals and in recent years has g/dL and the leukocyte count 10.7 been recognized as an uncommon 10.7 x 109/L with 92% neutrophils. cause of human disease.1 In humans Concentrations of serum constituents Y. enterocolitica may cause mesen- were as follows: bilirubin 5.3 mg/dL, teric lymphadenitis or appendicitis, alkaline phosphatase 939 lU/L, serum and sometimes it causes a form of glutamic oxaloacetic transaminase 180 terminal ileitis that must be distin- lU/L and albumin 2.4 g/dL. The blood guished from Crohn's disease.1 Poly- urea nitrogen concentration was 27 arthritis and erythema nodosum have mg/dL and the blood glucose conalso been described in humans infec- centration 428 mg/dL. Y. enterocolitica sensitive to gentated with this organism.1 Recently Y. enterocolitica has been identified as micin and trimethoprim was cultured the blood. a cause of septicemia and liver ab- from 60 mg q8h, was adGentamicin, scess. We describe the case of a man ministered intramuscularly and investiwith diabetes who presented with gations of liver function were consepticemia and liver abscess due to ducted. An intravenous cholangiogram Y. enterocolitica.3 showed no function of the gallbladder and did not demonstrate the biliary tree. Case report Ultrasonography, however, recorded a gallbladder and collecting sysA 64-year-old man who had had normal and endoscopic retrograde cholantem, diabetes mellitus for 16 years presented giopancreatography showed a to hospital with a 3-week history of normal gallbladder (ERCP) bile ducts. A and anorexia, intermittent fever and rigors, gallium-67 scan disclosed an area of sweating and a weight loss of 14 kg. uptake and a probable abscess in He required 30 U of NPH (iso- high the liver; a technetiumthe centre phane) insulin per day; his diabetes 99m scan of space-occupying showed was poorly controlled primarily be- lesion in the centre ofa the liver extendcause of poor dietary compliance. Six ing into the left lobe. vision his this admission months before A diagnosis of liver abscess was had become blurred and proliferative made. Laparotomy revealed two liver diabetic retinopathy was diagnosed. He abscesses, each approximately 4 cm in had had no other significant illness. No other abnormalities were He was moderately obese. His tem- diameter. in the abdominal viscera. The detected perature was 380C and spiked to 41 0C. abscesses contained a firm, cheesy maAside from proliferative diabetic retino- terial; necrotic liver metastases were considered as a diagnosis. Y. enteroFrom the departments of medicine and colitica was cultured from abscess masurgery, Ottawa Civic Hospital and terial, and specimens from biopsies of University of Ottawa the abscesses showed areas of acute Reprint requests to: Dr. J.E. Mullens, chronic inflammatory change with and Department of surgery, Ottawa Civic fibrosis, as well as necrosis with abscess Hospital, 1053 Carling Ave., Ottawa, formation. Ont. K1Y 4E9 922 CMA JOURNAL/OCTOBER 21, 1978/VOL. 119
The patient responded well to gentamicin therapy and was discharged taking a 6-week course of trimethoprim.
Discussion Y. enterocolitica, a gram-negative coccobacillus, is urease-positive, oxidase-negative and motile only at 250C.4 It was previously known as Bacterium enterocoliticum and Pasturella pseudotuberculosis type B. The organism will grow readily on standard media when specimens are taken from humans or animals.5'6 Nilehn and Sjostrom7 have isolated the organism from the gastrointestinal tract of 4% to 6% of patients with acute appendicitis. The isolation rate in controls was 0.1%. Septicemia caused by Y. enterocoutica is rare.8'9 At the time this report was written only two other proven cases of septicemia due to this organism had been described in Canada.10"1 Recently Reinicke and Korner3 reviewed the world literature and were able to find only 25 such cases. Y. enterocolitica usually produces a self-limiting infection confined to the gastrointestinal tract, but it can cause a life-threatening situation, especially in patients with chronic diseases such as diabetes mellitus, cirrhosis of the liver, leukemia or alcoholism, and in those receiving immunosuppressive therapy.'2 In the six previously reported cases of septicemia caused by Y. enterocoutica with associated liver abscess all six patients had either diabetes or cirrhosis of the liver and died of the infection. Only one patient with Y. enterocolitica liver abscess has sur-
vived, and this patient did not have associated septicemia.13 Our patient is the only one to have Y. enterocolitica septicemia and liver abscess and to survive.
other gram-negative bacteria. J Appi Bacteriol 24: 252, 1961 6. Hxssio A, KARRER J, PUSTERLA F: Ueber Pseudotuberkulose beim Menschen. Schweiz Med Wochenselir 79: 971, 1949 7. NILEHN B, SJOSTROM B: Studies on Yersinia enterocolitica. A cta Patliol
References
Microbiol Scand 206 (suppD: 8, 1969
1. LEINO R, KALLIOMAKI JL: Yersiniosis as an internal disease. Ann intern Med 81: 458, 1974 2. VANTRAPPEN G, PONETTE E, GEBOES K, et al: Yersinia enteritis and enterocolitis: gastroenterological aspects. Gastroenterology 72: 220, 1977 3. REINICKE V, KORNER B: Fulminant septicemia caused by Yersinia enterocolitica. Scand J infect Dis 9: 249, 1977 4. SCHLEIFSTEIN J, COLEMAN M: Bacterium enterocoliticum, annual report, division of laboratory research, New York State Department of Health, 1943, p 56 5. DICKINSON AB, MocQuo'r G: Studies on the bacterial flora of the alimentary tract of pigs. I. Enterobacteriacea and
BOOKS continued from page 886 PROCEEDINGS OF THE 1977 ASPIRIN FOUNDATION SYMPOSIUM. Proceedings of a Symposium Sponsored by the Aspirin Foundation and held at the Royal College of Surgeons, London, on 1 November 1977. Edited by John S. Goodall. 36 pp. Published as Volume 70, Supplement *7, 1977 of Proceedings of the Royal Society of Medicine. The Royal Society of Medicine, London for the Aspirin Foundation, London, 1977. Price not stated, paperbound. ISSN 0-308-2520 PSYCHOLOGICAL DISORDERS OF CHILDREN. A Handbook for Primary Care Physicians. Mark A. Stewart and Ann Gath. 167 pp. lIlust. The Williams & Wilkins Company, Baltimore; Burns & MacEachern Limited, Don Mills, 1978. $11.95, paperbound. ISBN 0-683-97179-9 PSYCHOPHARMACOLOGY FOR PRIMARY CARE PHYSICIANS. Charles L. Bowden and Martin B. Giffen. 91 pp. Illust. The Williams & Wilkins Company, Baltimore; Burns & MacEachern Limited, Don Mills, 1978. $10.75, paperbound. ISBN 0-683 010050-0 ROENTGENOLOGIC ANATOMY OF THE LUNG. Hideaki Yamashita. 389 pp. Illust. Igaku-Shoin, Tokyo; Igaku-Shoin, New York, 1978. $79.50. ISBN 0-89640028-X SYNOPSIS OF CLINICAL PULMONARY DISEASE. 2nd ed. Edited by Roger S. Mitchell. 352 pp. IlIust. The C.V. Mosby Company, Saint Louis, 1978. $12, paper. bound. ISBN 0-8016-3430-X THE YEAR BOOK OF DRUG THERAPY 1978. Edited by Daniel L. Azarnoff. 448 pp. IlIust. Year Book Medical Publishers, Inc., Chicago, 1978. $28.05. ISBN 0-81510387.5
continued on page 928
8. CHESSUM B, FRENGLEY JD, FLECK DG, et al: Case of septicaemia due to Yersinia enterocolitica. Br Med J
3: 466, 1971 9. MOLLARET HH, OMLAND T, HENRIKSEN SD, et al: Les septic.mies humaines . "Yersinia enterocolitica". A
propos de dix-sept cas r.cents. Noiiv Presse Med 79: 345, 1971 10. ABRAMOVITCH H, BUTAS CA: Septicemia due to Yersina enterocolitica.
Can Med Assoc J 109: 1112, 1973 11. NARASJMHAN SL, SCHIEVEN BC, CAMPSALL EWR: Septicemia caused by Yer-
sinia enterocolitica. Can Med Assoc J 118: 682, 1978 12. RABSON AR, KOORNHOF HF, NOrMAN J, et al: Hepatosplenic abscesses due
to Yersinia enterocolitica. Br Med J 4: 341, 1972 13. BLOQUIAUX W: Multiple Leverabscessen
door
Yersinia
enterocolitica.
Tijdschr Gastroenterol 11: 578, 1968
The year was 64 A.D.
Emperor Nero abused his stomach just as he abused his city Burningly And there w.a. no DiovoL -
N
*. .uv Diov l with Fresh Fruit Flavour S. P*fl.iOfltZj
D
the patient whose stomach's afire.
CCPP
Fresh Fruit FlavourDiovol antacid/antiflatulentsuspension contains perS ml 200mg aluminum hydrosicle equivalent to dried gel. 200mg magnesium hydroxide. 25mg simethicone Full prescribing intormation available on request
CMA JOURNAL/OCTOBER 21, 1978/VOL. 119 923
![[Liver abscesses due to Yersinia enterocolitica].](/assets/img/hold.png)
