Chapter 3Infectious Diseases Related To Travel
Kanyin L. Ong, Amy L. Boore, L. Hannah Gould
Yersiniosis is caused by facultative anaerobic gram-negative coccobacilli of the genus Yersinia. Most known human infections are associated with Yersinia enterocolitica serogroups O:3, O:5,27, O:8, and O:9. Infection with Y. pseudotuberculosis can also occur but is uncommon; Y. pseudotuberculosis infections tend to be more severe.
MODE OF TRANSMISSION
Y. enterocolitica is transmitted by consumption or handling of contaminated food products (most commonly raw or undercooked pork products), unpasteurized or inadequately pasteurized milk, untreated water, or by direct or indirect contact with animals. The epidemiology of other species has been less studied. However, these infections are generally thought to be transmitted through fecal contamination of food or water.
Yersiniosis is more common in cooler months in temperate climates. The highest incidence is reported in northern Europe (particularly Scandinavia), Japan, and Canada. The incidence of microbiologically confirmed yersiniosis was estimated to be 8 per 10,000 international travelers who sought care at travel clinics throughout the world.
People with high iron levels, such as those with chronic hemolysis, sickle cell disease, or β-thalassemia, or who are using iron-chelating agents such as deferoxamine, are at higher risk of infection and severe disease. The incidence among travelers to developing countries has been low in the few studies that specifically looked for Yersinia.
The incubation period is typically 4–6 days (range, 1–14 days). Common symptoms include fever, abdominal pain, and diarrhea, which may be bloody. The duration of diarrhea varies, but it can persist for several weeks. Abdominal pain in yersiniosis may mimic appendicitis. Necrotizing enterocolitis has been described in young infants. Bacteremia is rare and occurs most commonly in young children and infants with predisposing conditions such as excessive iron storage and immunosuppressive states.
Focal manifestations may occur rarely, including pharyngitis, meningitis, osteomyelitis, pyomyositis, conjunctivitis, pneumonia, empyema, endocarditis, acute peritonitis, abscesses of the liver and spleen, and primary cutaneous infection. Postinfectious sequelae are sometimes reported, predominantly in adults. Reactive arthritis affecting the wrists, knees, and ankles can occur, with onset usually 1 month after the initial diarrhea episode and symptoms typically resolving after 1–6 months. Erythema nodosum can also occur, manifesting as painful, raised red or purple lesions along the trunk and legs. This condition is more commonly reported among women; symptoms usually resolve spontaneously within 1 month.
Definitive diagnosis is made by isolating the organism from stool, blood, bile, wound, throat swab, mesenteric lymph node, cerebrospinal fluid, or peritoneal fluid. Most laboratories do not routinely test for Y. enterocolitica. If yersiniosis is suspected, the clinical laboratory should be notified and instructed to culture on CIN agar. Postinfectious sequelae, including reactive arthritis and erythema nodosum, are diagnosed clinically and serologically. Serologic tests for Y. enterocolitica serogroup O:9 may cross-react with tests for Brucella and Escherichia coli O157:H7.
Antibiotic treatment may reduce the duration of fecal shedding. However, the benefit of antibiotic therapy in uncomplicated cases is not well established. Antibiotic treatment should be given for severe cases, including patients with septicemia, metastatic focal infections, or underlying immunosuppression. Y. enterocolitica isolates are usually susceptible to trimethoprim-sulfamethoxazole, aminoglycosides, cefotaxime, fluoroquinolones, tetracycline, doxycycline, and chloramphenicol. Y. enterocolitica isolates typically are resistant to first-generation and most second-generation cephalosporins and most penicillins. Antimicrobial therapy has no effect on postinfectious sequelae.
PREVENTIVE MEASURES FOR TRAVELERS
No vaccine is available. Drugs for preventing infection are not recommended. Travelers should avoid raw or undercooked pork products, unpasteurized milk products, and untreated water (see Chapter 2, Food and Water Precautions).
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