Description of Event or Problem · 1
BACKGROUND: YERSINIOSIS IS A REPORTABLE DISEASE IN RPTR'S STATE. FROM 1997 TO 2001, 48-69 CASES WERE REPORTED ANNUALLY (MEDIAL OF 53 CASES PER YEAR). MOST OF THESE CASES ARE DUE TO INFECTION WITH YERSINIA ENTEROCOLITICA, BUT OCCASIONALLY OTHER SPECIES ARE REPORTED. SOURCE OF THE ISOLATE IS NOT ALWAYS REPORTED. MOST ISOLATES COME FROM STOOL (14-26 PER YEAR), WITH A FEW FROM URINE (1-4 PER YEAR) OR BLOOD (1-5 PER YEAR). DURING THE YEARS 1997 TO 2001, ONLY ONE ISOLATE FROM A WOUND WAS REPORTED (2001). IN ADDITION TO CASES BEING REPORTED THROUGH THE USUAL DISEASE REPORTING CHANNELS, ISOLATES ARE SOMETIMES RECEIVED AT DEPT OF HEALTH LAB FOR IDENTIFICATION. THESE REPORTS WOULD ALSO BE INCLUDED IN THE DISEASE STATISTICS. THIS IS THE CONTEXT IN WHICH THE CURRENT REPORTS OCCURRED. SUMMARY: EIGHT ISOLATES OF YERSINIA SPP FROM SOURCES OTHER THAN STOOL OR URINE WERE REPORTED TO THE DEPT OF HEALTH IN APRIL AND MAY, 2002; AN ADD'L ONE IS PENDING. THEY WERE ALL OBTAINED POST-SURGERY. INITIALLY, THE LAB FOR FACILITIES A AND B (ACTUALLY LOCATED AT FACILITY A) REPORTED 5 ISOLATIONS FROM POST-SURGICAL SPECIMENS. LAB VERIFIED THE IDENTIFICATION OF THESE ISOLATES AS YERSINIA ENTEROCOLITICA. BY PULSED-FIELD GEL ELECTROPHORESIS (PFGE) 4 WERE IDENTICAL; REFERRED TO BY LAB AS PATTERN 1. PFGE ON THE FIFTH ISOLATE IS UNDERWAY. THE LAB FOR FACILITIES A AND B RECOVERED THE YERSINIA ENTEROCOLITICA ON "CDC BLOOD AGAR OXYPLATE" MFG BY OXYRASE (SEE WWW.OXYRASE.COM. OXYRASE, INC; P.O. BOX 1345, MANSFIELD, OH 44901; TEL 419/589-8800). THIS IS AN ANAEROBIC BLOOD AGAR PLATE. FACILITY A DETERMINED THAT THE OXYPLATE WAS THE SOURCE OF THE YERSINIA, AND CONTACTED THE CO TO REPORT THEIR FINDINGS THAT THE PLATES WERE CONTAMINATED. FACILITY C REPORTED A POST-SURGERY FINDING OF YERSINIA ENTEROCOLITICA. LAB VERIFIED THE IDENTIFICATION AND PFGE ANALYSIS IDENTIFIED IT AS DISTINCT FROM PATTERN 1; IT IS CALLED PATTERN 2. THIS LAB WAS USING PLATES FROM BECTON DICKINSON (INITIALLY THEY REPORTED USING PLATES FROM BBL). FACILITY D GREW YERSINIA SPP FROM A POST-SURGICAL SWAB RECEIVED FROM A DR'S OFFICE. THEY FORWARDED THE ISOLATE TO HEALTH DEPT LAB FOR FURTHER IDENTIFICATION, WHERE IT WAS IDENTIFIED AS YERSINIA KRISTENSENII. THIS LAB WAS USING PLATES FROM BBL. FACILITY E GREW YERSINIA FROM A POST-SURGICAL SWAB FROM A DR'S OFFICE. THEY FORWARDED IT TO FACILITY D, WHO SENT IT ON TO LAB WITHOUT DOING ANYTHING TO IT. LAB IDENTIFIED IT AS YERSINIA ENTEROCOLITICA, PFGE PATTERN 3, DISTINCT FROM PATTERNS 1 AND 2. FACILITY E LAB WAS USING PLATES FROM BECTON DICKINSON. LASTLY, THERE IS AN ISOLATE PENDING FROM FACILITY F, WHICH REPORTED FINDING YERSINIA ENTEROCOLITICA IN A GALLBLADDER. THIS ISOLATE WAS SUBMITTED TO LAB IN RESPONSE TO A MEMO SENT TO ALL MICROBIOLOGY LABS IN STATE BY HEALTH DEPT ON 5/2002, SOLICITING ALL NON-STOOL ISOLATES OF Y. ENTEROCOLITICA. FACILITY F LAB WAS USING MEDIA FROM BBL. LAB IS IN THE PROCESS OF IDENTIFYING THIS ISOLATE (6/2002). (NOTE: IT APPEARS THAT BECTON DICKINSON SELLS BBL MEDIA). IN SUMMARY, THIS CLUSTER OF POST-SURGICAL SPECIMENS YIELDING YERSINIA SPP IS VERY UNUSUAL IN THE STATE, WHERE MOST YERSINIOSIS IS REPORTED FROM STOOL CULTURES, FROM PTS HAVING DIARRHEA. THE PRESENCE OF TWO SPECIES OF YERSINIA, AND 3 STRAINS OF Y. ENTEROCOLITICA SUGGESTS A MIXED YERSINIA FLORA IS INVOLVED. DETAILED CASE REPORTS: CASES 1,2,3,4 AND 10 ARE ASSOCIATED WITH FACILITIES A AND B. THESE ARE TWO SEPARATE HOSPS THAT ARE AFFILIATED. THEY SHARE ONE LAB (LOCATED AT FACILITY A). THEY ORDER SUPPLIES TOGETHER. THEY ARE NOT AFFILIATED WITH ANY OTHER FACILITY. THE INITIAL REPORT CAME FROM A COUNTY HEALTH DEPT THAT FACILITIES A AND B WERE REPORTING TWO POSITIVE YERSINIA CULTURES OCCURRING WITHIN 2 DAYS FROM POST-SURGICAL PTS. RPTR LEARNED ABOUT THIS CASE WHEN LAB REPORTED THE IDENTIFICATION OF THE ISOLATE AS YERSINIA ENTEROCOLITICA. LAB RECEIVED THE ISOLATE FROM FACILITY D, WHO RECEIVED IT FROM FACILITY E, WHICH IS LOCATED IN ANOTHER STATE. PT HAD A SUPERFICIAL RIGHT HEEL WOUND. THEY WERE SEEN BY A NURSE PRACTITIONER AT A CLINIC. THE NURSE PRACTITIONER PROVIDED THE HISTORY. THIS PT CAME IN WITH A LARGE BLISTER ON RIGHT HEEL WHICH THEY HAD FOR THE PAST MONTH. PT HAD BEEN SQUEEZING PUS OUT OF IT. THE LESION WAS CLEANED WITH BETADINE ANTI-SEPTIC, FOLLOWED BY NORMAL SALINE (SUPPLIED TO THE CLINIC BY FACILITY E). IT WAS INCISED AND THEN A SWAB OF THE PUS WAS TAKEN AND PLACED IN A CULTURETTE (ALSO SUPPLIED BY FACILITY E). A COURIER TOOK THE CULTURETTE TO FACILITY E'S LAB. THE PT WAS PUT ON ORAL AUGMENTIN. THREE DAYS LATER THE PT CAME IN FOR A CHECK UP ON THE HEEL AND IT WAS IMPROVED. THE PT HAD BEEN TAKING THE ANTIBIOTICS. PT DID NOT COME IN FOR NEXT FOLLOW-UP APPOINTMENT. AT FACILITY E, THEY PUT THE SWAB ONTO BLOOD AGAR, MACCONKEY AGAR, AND CHOCOLATE AGAR, AND IT GREW ON ALL THREE MEDIA. THESE WERE ALL AEROBIC MEDIA. NO ANAEROBIC CULTURES WERE ORDERED. THEIR IDENTIFICATION WAS GROWING IN A WOUND LIKE THIS, SO THEY TRANSFERRED IT ON TO A FRESH BLOOD PLATE AND SENT IT TO FACILITY D FOR IDENTIFICATION. FACILITY D RECEIVED IT ON A BLOOD AGAR PLATE BUT THEY DID NOT RE-CULTURE IT. INSTEAD THEY FORWARDED IT TO LAB FOR IDENTIFICATION. THE MICROBIOLOGIST AT FACILITY E COULD NOT RECALL ANY OTHER RECENT NON-STOOL YERSINIA. (YERSINIOSIS IS NOT REPORTABLE IN THIS OTHER STATE.)