Yersinia hepatitis

Ierisiniosis is common and is registered in all countries of the world. For example, in Belarus the incidence rate fluctuates between 3.6 and 4.2 cases per 100,000 population.

In Russia, according to statistics, very monotonous rates of yersiniosis morbidity are observed. Thus, pseudo-tuberculosis was registered in 2006 with a frequency of 3.14 cases, and in 2008 - 2.63 cases per 100 thousand of the population, while the incidence of children was very high, amounting to 11.49 in 2006, and 12.55 cases per 100 thousand of the child population of Russia in 2008.

According to research data, the incidence of intestinal yersiniosis at the end of the 20th century in Russia was somewhat lower than pseudo-tuberculosis, and the frequency of intestinal yersiniosis varied significantly across regions of the country - from 1.5 to 15.5%.

The consistently low level of officially registered incidence of yersiniosis does not reflect the true state of the disease.

Yersiniosis occurs both sporadically and in the form of epidemic outbreaks.

In all countries of the world, pseudotuberculosis mainly affects children; intestinal yersiniosis affects children and adults.

How does Yersinia hepatitis develop?

Liver damage most likely occurs not so much due to the penetration of Yersinia into the liver parenchyma, but due to the effect of toxins on diaper cells. Immunological mechanisms aimed at eliminating toxin-containing hepatocytes cannot be ruled out. Currently, a large number of studies have been conducted indicating the participation of the T- and B-systems of immunity in Yersinia infection. According to L.I. Vasyakina (2001), in the acute phase of Yersinia hepatitis, suppression of both links of the immune response occurs, while Th1- and Th2-variants of the immunological response are weakly expressed.

Morphology

Morphological changes in the liver in both yersinioses are similar. Discomplexation of the liver beams, lymphocytic infiltration with a large number of plasma cells, with the presence of eosinophils, dystrophic changes in hepatocytes, focal necrosis of liver cells against the background of a moderate granulocytic reaction, small abscesses are possible are detected. Fibroblasts accumulate on the outer side of the granulomas and a connective tissue capsule is formed. Destruction and inflammatory infiltration of the bile ducts are observed.

Symptoms of Yersinia Hepatitis

Yersiniosis hepatitis is characterized by an acute onset of the disease with an increase in body temperature, mainly up to 38-39 °C, symptoms of intoxication in the form of lethargy, weakness, loss of appetite, abdominal pain. The appearance of jaundice is noted on the 4th-6th day of the disease, less often - on the 2nd week from the onset of the disease, against the background of persistent fever. Palpation of the abdomen reveals pain in the right hypochondrium and epigastric region. In all patients, according to our observations and according to other authors, the liver increases in size, while it is palpated 1.5-4 cm below the costal margin, sensitive and even painful, of a compacted consistency. Concomitant enlargement of the spleen is observed in 20-50% of cases.

In some patients with yersiniosis hepatitis [according to research data, in 6 out of 15, and according to observations of D.I. Shakhgildyap et al. (1995) - in the majority], a scarlet fever-like rash on the skin with subsequent peeling is simultaneously recorded.

Almost all patients have palpated lymph nodes, mainly anterior and posterior cervical, submandibular, axillary, inguinal; these lymph nodes are 5-10 mm in diameter, painless, mobile. Changes in the oropharynx are scanty. All patients have mild or moderate hyperemia of the tonsils and arches. The tonsils are moderately hypertrophied and clean. The tongue is coated with a whitish coating, papillary tongue is rarely observed. Jaundice in yersiniosis hepatitis varies from mild to moderate, and in some cases it is intense.

Changes in the biochemical blood test are typical and are expressed in an increase in the level of total bilirubin with a predominance of the conjugated fraction of the pigment, an increase in the activity of aminotransferases, sometimes GTP and ALP, in cases with clear signs of cholestasis.

According to research data, there is a very wide range of bilirubin levels - from 30 to 205 μmol/l, with the level of the conjugated fraction necessarily exceeding the level of free bilirubin.

Hyperfermentemia fluctuates within the range of a 3-10-fold increase in ALT and AST, but in some patients the increase in transaminase activity exceeds the norm by 40-50 times.

The clinical blood test does not reveal any significant changes, except for individual cases. Thus, according to research data, in 13 out of 15 children with Yersinia hepatitis, the leukocyte level was normal, without changes in the neutrophil formula. Only in 2 patients, the leukocyte level was elevated to 10.0x10 ⁹ with a moderate left band shift; in them, ESR was elevated to 20-24 mm/h.

Flow options

Yersiniosis hepatitis is characterized by a benign course. The formation of a chronic process is not observed. At the same time, yersiniosis is characterized by a course with exacerbations and relapses of the disease. It is noted that in case of group yersiniosis, the frequency of the wave-like and recurrent course of the disease is higher than in sporadic cases, while in sporadic pseudo-tuberculosis it is 19.3%, and in intestinal yersiniosis - 16.4%.

Diagnosis of Yersinia hepatitis

Diagnosis of yersiniosis, especially at the pre-hospital stage, is always difficult, both in adults and in children. According to N.P. Kuprina et al. (2002), only in 1/3 of sick children was the diagnosis of yersiniosis made at the onset of the disease. In adult patients, the diagnosis of yersiniosis made at the pre-hospital stage coincides with the final diagnosis only in 26.4% of cases.

Difficulties in diagnosing yersiniosis arise due to the clinical diversity of the disease picture. In cases of hepatitis syndrome as the leading one, the diagnosis of yersiniosis is made extremely rarely.

Laboratory diagnostics in the form of bacteriological and serological testing is of great importance for diagnosing yersiniosis. Bacteriological testing of feces, urine, blood and other biological substrates is currently not informative enough.

According to G.Ya. Tsensva et al. (1997), the effectiveness of bacteriological research in outbreak cases on the 5th day from the onset of the disease does not exceed 67%, on the 10th day - 36.7, on the 15th day - 45, and in sporadic cases - 3-25%.

Serological methods are divided into two groups: methods based on the determination of antibodies to the pathogen in the blood serum, and methods for directly detecting bacterial antigens in various biological substrates (blood, urine, coprofiltrate, saliva).

To determine antibodies to Yersinia, an agglutination reaction and RIGA are performed with commercial erythrocyte diagnostics.

In pseudo tuberculosis, specific agglutinins appear in the first week of the disease, but increase by the period of convalescence. For example, in the first week of the disease, antibodies are detected only in 30% of patients in titers of 1:100, and in the 2nd, 3rd, 4th and 5th weeks they are detected in 65.7; 65.9; 70 and 69.8%, respectively, with an increase in titers by 2 times or more, compared to the initial ones.

According to N.P. Kuprina et al. (2000), a clear increase in the titers of specific antibodies in yersiniosis is observed in the 3rd-4th week of the disease, with antibody titers reaching 1:800-1:1200. However, in 30% of patients, the diagnosis of yersiniosis was made only on the basis of clinical and epidemiological data, since the results of serological studies were negative and.

Among the 5 patients with yersiniosis hepatitis that we observed, specific antibodies were detected in 10 in titers from 1:100 to 1:800, usually on the 3rd-5th week of the disease.

In adult patients with intestinal yersiniosis in generalized forms of the disease, specific antibodies are detected in high titers - up to 1:6400.

Detection of Yersinia antigens is most effective in coprofiltrates during the first week of the disease. For example, Yersinia antigens are detected in this period in coprofiltrates in 40-80% of cases, and in intestinal yersiniosis, the frequency of detection of the pathogen antigen is 31-51.6%.

Yersinioses, due to their clinical polymorphism, have to be differentiated from many infectious diseases. For example, differential diagnostics are carried out with acute respiratory viral infections, acute intestinal infections, infectious mononucleosis, scarlet fever, rubella, cytomegalovirus, septic and typhoid-like infections. When predominantly hepatitis syndrome manifests, it is necessary to exclude viral hepatitis. Negative results of serological analysis for hepatitis virus markers are of decisive importance.

At the same time, it is known that yersiniosis can occur in combination, as a mixed infection, with viral hepatitis A, B, C, including chronic viral hepatitis. When differentiating yersiniosis hepatitis and viral hepatitis in clinical terms, the following are important: a long period of subfebrile and febrile temperature in yersiniosis, the presence of catarrhal phenomena in the oropharynx, an increase in several groups of lymph nodes, the appearance in some patients of a small-point or maculopapular rash on the skin with subsequent peeling, which is not observed in viral hepatitis. Of certain importance is the epidemiological anamnesis regarding the consumption of raw vegetables, milk and other dairy products, especially in cases of group disease.

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Treatment of Yersinia Hepatitis

In etiotropic therapy for yersiniosis, metronidazole (Trichopolum), rifampicin, chloramphenicol (levomycetin) are used, with restrictions in young children. In adults, tetracycline drugs are widely used, primarily doxycycline. Third-generation fluoroquinolones (ciprofloxacin) are prescribed for adult patients with yersiniosis. If parenteral administration is necessary, third-generation cephalosporins are prescribed, as well as aminoglycosides (amikacin, sisomicin), chloramphenicol (levomycetin succinate).

Antibiotics are given for 10 days, in severe forms of the disease - 2-3 weeks.

One of the important criteria for discontinuing antibacterial therapy is the normalization of body temperature; regression of pathological clinical manifestations is also taken into account.

Prevention of Yersinia hepatitis

To prevent infection with yersinia, it is necessary to comply with sanitary and hygienic standards for the storage, processing and sale of food products, especially vegetables. Specific prevention has not been developed.