Case history
Case history #1
A 30-year-old man presents with abrupt onset of fever, myalgia, and headache. Shortly after first feeling unwell he noticed a painful swelling in his right groin. Two days previously he had returned from a camping expedition in New Mexico. Towards the end of his trip he noticed several small bites on his legs, and these were intensely itchy. On examination he appears unwell and has a temperature of 39.4°C (103°F). Movement of his right leg is limited by the painful swelling in his groin, and he walks with a limp. On the examination couch he is holding his leg flexed and in external rotation. The groin swelling is 5 cm long and tender to touch; it does not appear to be fluctuant. The overlying skin is warm and erythematous with some surrounding oedema.
Case history #2
A 23-year-old woman presents with a 2-week history of bilateral, painful, swollen knees and tender erythematous lesions over her shins. She was previously well but recently had a prolonged bout of diarrhoea associated with abdominal pain. The diarrhoea lasted for 10 days and she was having 8 blood-stained watery bowel movements every day. No family or friends were unwell. Her gastrointestinal symptoms eventually settled without specific treatment. The joint pain started 1 week after the diarrhoea settled and is associated with a tender rash on both shins.
Other presentations
The most common clinical presentation of plague in humans is bubonic plague. Haematogenous spread of bacteria may lead to secondary septicaemic, pneumonic, or meningeal plague. Less common clinical presentations include meningitis and pharyngitis.[2]
Several clinical syndromes of Yersinia enterocolitica infection have been described.[3] Enterocolitis is the most common syndrome in young children and may cause bloody stools. Older children may develop terminal ileitis and mesenteric adenitis, and the clinical presentation may be indistinguishable from acute appendicitis. Adults generally present with diarrhoea and abdominal pain, which may last for ≥3 weeks. Invasive disease is more likely to occur in patients with diabetes, chronic liver disease, alcoholism, or iron-overload syndromes.[4] Infection is followed by reactive arthritis in up to 30% of patients, more commonly in patients carrying the human leukocyte antigen-B27 genotype.[5]
Yersinia pseudotuberculosis infection most commonly causes mesenteric adenitis. Enteritis is infrequent. Invasive disease is not common but may be seen in patients with chronic liver disease or haemochromatosis.[3]
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