S2598 Yersiniosis: The Other Great Imitator

Abstract

INTRODUCTION: Yersinia entercolitica is a Gram-negative bacterium that causes foodborne illnesses, typically characterized by acute febrile gastroenteritis and associated with a variety of gastrointestinal and extraintestinal manifestations. Isolated febrile illness without gastrointestinal symptoms is rare. We report a case of Y. entercolitica infection with severe anicteric hepatitis. CASE DESCRIPTION/METHODS: A 33-year-old Chinese male with no significant medical history presented on multiple occasions to the emergency department with recurrent high grade fever with chills without gastrointestinal symptoms. No recent travel, sick contacts, alcohol abuse or high risk behaviors noted. Initial labs were remarkable only for mild neutropenia with normal hepatic panel. Computed tomography of the abdomen revealed terminal ileitis and mesenteric adenitis. Repeat hepatic panel showed gradually raising transaminases over the next 2 weeks that peaked at AST of 991 U/L and ALT of 1664 U/L. He had normal bilirubin and alkaline phosphatase. He was given a 14-day course of empiric doxycycline for suspected typhus fever with resolution of fever. In the setting improvement of his symptoms yet rising liver chemistries, he was referred to hepatology. Extensive non-infectious and infectious work-up was unremarkable (acute hepatitis viral panel, malaria, TORC panel, CMV, HSV, EBV, TB, rickettsial panels, HIV, Widal, blood and stool cultures/PCR). As part of work-up for terminal ileitis, we found positive serology for Yersinia enterolitica IgM, IgG, and IgA. Ultimately, he improved with supportive care. His hepatic panel normalized in 6 weeks and repeat CT scan after 3 months showed resolution of earlier mentioned radiographic findings. DISCUSSION: Yersiniosis is a great imitator. Here, it masqueraded as a ricketisial illness—given high rate of tick-borne illnesses in Southwest Texas. The fever pattern mimicked malaria. Given his demographics, the imaging findings imitated Crohn’s disease and tuberculosis. While rare, yersinosis is known to have hepatic involvement. This case highlights the importance of thorough work-up of terminal ileitis and “Crohn's mimics” which ultimately revealed a unifying diagnosis. With minimal cofounding factors and resolution with antibiotics, it is easier to attribute his severe anicteric hepatitis to Yersiniosis. Therefore, this case highlights an important addition to the work-up for severe isolated hepatocellular liver injury (AST, ALT >15x ULN).Figure 1.: CT abdomen/pelvis with focal moderate thickening of the wall of the terminal ileum consistent with terminal ileitis.Figure 2.: Three month follow-up CT abdomen/pelvis imaging with resolution of terminal ileitis.Figure 3.: Hepatocellular liver chemistry trend during the course of yersiniosis illness.