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A 32 year old man presented with a 3 day history of fever, central abdominal pain, and frequent loose bowel motions without blood or mucus. The pain had recently shifted to his right iliac fossa. He had previously been well and he was receiving no regular drugs. On examination he was systemically well, but rebound tenderness was noted in the right iliac fossa, and C reactive protein (CRP) was raised (78 mg/l, reference range <10). A diagnosis of acute appendicitis was made and he underwent appendicectomy. Histology disclosed serosal congestion with a predominantly eosinophilic infiltrate in the mucosa and deeper layers.
Postoperatively the fever resolved, but the diarrhoea continued for several weeks. Two weeks later he developed a right knee effusion associated with raised inflammatory markers (CRP 37 mg/l). Subsequently, the left knee and right elbow also swelled, with 1 hour of morning stiffness. Synovial fluid from the knee and blood cultures was sterile; the diarrhoea was mild and stool cultures were not performed. Treatment with non-steroidal anti-inflammatory drugs and sulfasalazine was started. The arthritis resolved over the next 3 months, with normalisation of inflammatory markers; at the last review the patient had stopped all treatment and was well.
Serological testing showed raised titres (1/1280) of antibodies to Yersinia enterocolitica O:3 (⩾1/160 being considered significant), which remained at 1/640 3 months later.
On the basis of the clinical picture and serology a diagnosis of yersiniosis was made.
Reactive arthritis following enteric Y enterocolitica infection is well described.1Y enterocolitica and Y pseudotuberculosis are also well known causes of mesenteric adenitis, ileocolitis, and appendicitis,2 but reports of reactive arthritis following Y enterocolitica appendicitis are surprisingly rare.3,4
Pure cultures of Y enterocolitica have occasionally been isolated from acutely inflamed appendices, suggesting a primary pathogenic role for this species.5 Serological evidence of acute infection by Y enterocolitica was also reported in three of 90 patients with acute appendicitis;6 of these, two had postoperative diarrhoea. In another series7 evidence of Y enterocolitica or Y pseudotuberculosis was found by a polymerase chain reaction technique in 10 of 40 cases of granulomatous appendicitis but in none of 30 cases of non-granulomatous appendicitis.
An unexpected feature of this case was that granulomas were not seen on histology. The significance of the eosinophilia is uncertain, but in other respects the histology was typical of acute appendicitis. The association of appendicitis and yersinia induced reactive arthritis appears to be surprisingly unusual, despite the common occurrence of each condition individually. Nevertheless, it is clearly important for physicians to be aware that abdominal pain in patients with reactive arthritis may signify the potentially lethal complication of appendicitis, and for surgeons to be aware that appendicitis may be complicated by reactive arthritis.
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