A fatal case of post-appendectomy disseminated intravascular coagulation (DIC)

Yersinia enterocolitica is a facultative anaerobic Gram-negative coccobacillus that can cause self-limiting gastroenteritis, mesenteric adenitis or, occasionally, se- vere systemic illness [1]. Patients with iron overload who receive desferrioxamine (DFX) as iron chelator, appear to have increased susceptibility to Y. enterocolitica infection [2]. Iron is an important growth factor for bacteria which produce and release chelators known as siderophores that, after binding and solubilizing ferric iron, enter the cell through a specific receptor. Yersinia enterocolitica is an abnormal bacterium which cannot produce chelators but can utilize DFX as siderophores increasing its growth and its virulence [3–4]. We work in the South of Italy, a high prevalence area for beta-thalassemia and in the course of our clinical activities, we observed four young patients (three males, mean age 19) who were receiving occasional blood transfusions and DFX therapy for chronic iron overload because of beta-thalassemia major. They came to our attention because of acute pain in the right iliac fossa and fever. Splenectomy had been carried out in patients 3 and 4. In patient 1, appendectomy was performed and, at histology, catarrhal appendicitis was found. However, because of persistence of fever and leucocytosis, the patient was submitted to abdominal computed tomo- graphy scan that revealed mesenteric suppurative lymph- adenopathy. A second operation to drain the abscess resulted in successful resolution of the illness. Cultures from the abscess revealed Y. enterocolitica infection. In patient 2, after blood culture analysis confirming Y. enterocolitica infection, timely antibiotic therapy was started which led to recovery of the patient. Despite antibiotic therapy for Y. enterocolitica infec- tion, guided by blood culture analysis, fever and leuco- cytosis persisted in patients 3 and 4. At ultrasonography, a mesenteric abscess was discovered and drained in both of these patients who subsequently healed. The diagnosis of Y. enterocolitica infection should be considered in any patient with iron overload who presents a pseudoappendicular syndrome characterized by abdom- inal pain, high temperature and tenderness to palpation in the right lower quadrant. In this way timely adequate antibiotic therapy can be administered, preventing com- plications such as mesenteric adenitis or sepsis. Previous splenectomy appears to predispose to the infection [5]. In cases of persistence of the mesenteric abscess, a surgical approach may be necessary