What is the clinical significance of a 55-year-old male with a history of hypertension (HTN), gastroesophageal reflux disease (GERD), gout, remote pulmonary embolism (PE) on Xarelto (rivaroxaban), acute cholecystitis status post percutaneous cholecystostomy and cholecystectomy, large B-cell lymphoma status post chemotherapy with a cecal mass status post donor lymphocyte infusion (DLI) and reversal, now presenting with small bowel obstruction (SBO) and found to have a large left lower quadrant (LLQ) colon mass and a positive gastrointestinal polymerase chain reaction (GI PCR) panel for Yersinia enterocolitica?

From the Guidelines

This patient requires immediate treatment with a 7-10 day course of fluoroquinolones (ciprofloxacin 500mg twice daily) or trimethoprim-sulfamethoxazole (TMP-SMX DS twice daily) for the Yersinia enterocolitica infection, while closely monitoring his post-operative recovery from small bowel resection with ostomy creation. The patient's clinical picture is complex, with a recent small bowel obstruction requiring surgery, an incidental finding of a large left lower quadrant colon mass, and a Yersinia enterocolitica infection detected on GI PCR panel 1. The Yersinia infection may be related to or mimicking the colon mass, and treatment should be initiated promptly to prevent further complications. Key considerations in this patient's management include:

• The patient's immunocompromised state due to lymphoma history, which can lead to more severe and atypical presentations of Yersinia infections 1
• The potential for Yersinia enterocolitica to cause terminal ileitis, mesenteric lymphadenitis, and inflammatory masses that can be confused with malignancy or Crohn's disease 1
• The importance of close monitoring of the patient's post-operative recovery, with attention to ostomy function and signs of infection
• The need for biopsy results of the colon mass to determine if this represents inflammatory pseudotumor formation from Yersinia or a true neoplastic process
• The potential need for colonoscopy after antibiotic treatment to reassess the colon mass and determine if further intervention is required. In terms of specific treatment, fluoroquinolones or trimethoprim-sulfamethoxazole are recommended for Yersinia enterocolitica infections 1, and the patient's treatment should be tailored to his individual needs and medical history.

From the Research

Patient's Condition

The patient is a 55-year-old male with a significant past medical history, including:

• Hypertension (HTN)
• Gastroesophageal reflux disease (GERD)
• Gout
• Remote pulmonary embolism (PE) on Xarelto
• Acute cholecystitis with percutaneous cholecystostomy and cholecystectomy
• Large B-cell lymphoma with chemotherapy and complications, including a cecal mass and diffuse large B-cell lymphoma (DLBCL) with reversal
• Currently admitted for small bowel obstruction (SBO) and is post-operative day 3 (POD3) after exploratory laparotomy with small bowel resection (SBR), end ileostomy, and cecal mucous fistula
• Incidently found large left lower quadrant (LLQ) colon mass during surgery, with biopsy taken and sent for pathology
• GI PCR panel positive for Yersinia enterocolitica

Yersinia Enterocolitica Infection

• Yersinia enterocolitica is a heterogeneous group of strains, with human pathogenic strains most frequently isolated worldwide belonging to serogroups O:3, O:5,27, O:8, and O:9 2
• The major route of Y. enterocolitica infection is through contaminated foods or water, with the primary pathogenic event being colonization of the intestinal tract 2
• Gastrointestinal infections are usually self-limiting and do not require antimicrobial therapy, but fluoroquinolones or third-generation cephalosporins may be warranted in compromised hosts or patients with septicemia or invasive infection 2

Treatment Options

• Antibiotic treatment options for Yersinia enterocolitica infections include:
  • Fluoroquinolones (e.g., ciprofloxacin) 3, 4, 5
  • Third-generation cephalosporins (e.g., ceftriaxone) 3, 4
  • Doxycycline 3
  • Co-trimoxazole 3
• The choice of antibiotic should be guided by the bacteriologic susceptibilities of the medical center and the patient's individual needs 6

Considerations

• The patient's complex medical history and current condition may require careful consideration of antibiotic therapy, including potential interactions with other medications and the risk of developing resistance 6
• The incidentally found colon mass and positive GI PCR panel for Yersinia enterocolitica may indicate a need for targeted antibiotic therapy, but further evaluation and consultation with infectious disease specialists may be necessary to determine the best course of treatment 2, 3, 4, 5