{"version":"1.0.0","segments":[{"startTime":0.419,"endTime":3.3,"body":"[upbeat intro music]"},{"startTime":3.3,"endTime":5.7,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.3,"endTime":5.7,"body":"to Harrison's PodClass,"},{"startTime":5.7,"endTime":8.842,"body":"where we discuss important"},{"startTime":5.7,"endTime":8.842,"body":"concepts in internal medicine."},{"startTime":8.842,"endTime":10.07,"body":"I'm Cathy Handy."},{"startTime":10.07,"endTime":11.74,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":10.07,"endTime":11.74,"body":"Wiener, and we're coming to you"},{"startTime":11.74,"endTime":13.84,"body":"from the Johns Hopkins School of Medicine."},{"startTime":15.91,"endTime":17.91,"body":"[Dr. Handy] Welcome, everyone, episode 94,"},{"startTime":17.91,"endTime":20.11,"body":"today we'll be talking about a 15-year-old"},{"startTime":20.11,"endTime":22.13,"body":"with right lower quadrant pain."},{"startTime":22.13,"endTime":24.327,"body":"[Dr. Wiener] Okay, Cathy,"},{"startTime":22.13,"endTime":24.327,"body":"today you're caring for"},{"startTime":24.327,"endTime":26.52,"body":"a 15-year-old student who presented"},{"startTime":26.52,"endTime":27.38,"body":"to the emergency department"},{"startTime":27.38,"endTime":30.66,"body":"with right lower quadrant"},{"startTime":27.38,"endTime":30.66,"body":"pain that started yesterday."},{"startTime":30.66,"endTime":33.32,"body":"Given his presentation,"},{"startTime":30.66,"endTime":33.32,"body":"he was taken emergently"},{"startTime":33.32,"endTime":35.3,"body":"to the operating room for an appendectomy."},{"startTime":35.3,"endTime":37.44,"body":"However, on exploratory laparotomy,"},{"startTime":37.44,"endTime":39.2,"body":"his appendix appeared quite normal"},{"startTime":39.2,"endTime":41.2,"body":"and the surgeon visualized striking"},{"startTime":41.2,"endTime":44.52,"body":"mesenteric adenitis and terminal ileitis."},{"startTime":44.52,"endTime":47.22,"body":"The operation was aborted"},{"startTime":44.52,"endTime":47.22,"body":"without further intervention"},{"startTime":47.22,"endTime":49.92,"body":"and he was admitted to the"},{"startTime":47.22,"endTime":49.92,"body":"medical intensive care unit."},{"startTime":49.92,"endTime":50.94,"body":"On further questioning,"},{"startTime":50.94,"endTime":53.0,"body":"the patient endorsed eating chitterlings"},{"startTime":53.0,"endTime":55.3,"body":"at a family gathering a week prior."},{"startTime":55.3,"endTime":57.05,"body":"You suspect his infection is due"},{"startTime":57.05,"endTime":58.62,"body":"to which of the following?"},{"startTime":58.62,"endTime":61.32,"body":"A. Clostridium difficile;"},{"startTime":61.32,"endTime":63.65,"body":"B. E. Coli;"},{"startTime":63.65,"endTime":66.29,"body":"C. Staph aureus;"},{"startTime":66.29,"endTime":68.97,"body":"D. Trichinella spiralis;"},{"startTime":68.97,"endTime":72.39,"body":"or E. Yersinia enterocolitica."},{"startTime":72.39,"endTime":74.72,"body":"[Dr. Handy] Can we first"},{"startTime":72.39,"endTime":74.72,"body":"discuss what are chitterlings?"},{"startTime":74.72,"endTime":78.17,"body":"Are those the same as"},{"startTime":74.72,"endTime":78.17,"body":"chitlins popular in the south?"},{"startTime":78.17,"endTime":80.73,"body":"[Dr. Wiener] Yes, well,"},{"startTime":78.17,"endTime":80.73,"body":"chitterlings are common dish"},{"startTime":80.73,"endTime":82.83,"body":"prepared from pig intestines."},{"startTime":82.83,"endTime":84.28,"body":"Essentially, every culture"},{"startTime":84.28,"endTime":87.3,"body":"that consumes pork has"},{"startTime":84.28,"endTime":87.3,"body":"a version of this dish."},{"startTime":87.3,"endTime":91.82,"body":"They can be grilled,"},{"startTime":87.3,"endTime":91.82,"body":"stuffed, stewed, or fried."},{"startTime":91.82,"endTime":94.22,"body":"I can honestly say that"},{"startTime":91.82,"endTime":94.22,"body":"I'm not a huge fan,"},{"startTime":94.22,"endTime":96.91,"body":"but that has little"},{"startTime":94.22,"endTime":96.91,"body":"bearing on this question."},{"startTime":96.91,"endTime":98.0,"body":"[Dr. Handy chuckles] All"},{"startTime":96.91,"endTime":98.0,"body":"right, so let's go back"},{"startTime":98.0,"endTime":99.65,"body":"to the patient presentation here."},{"startTime":99.65,"endTime":102.41,"body":"So he had an emergent"},{"startTime":99.65,"endTime":102.41,"body":"exploratory laparotomy"},{"startTime":102.41,"endTime":104.01,"body":"for presumed appendicitis,"},{"startTime":104.01,"endTime":105.8,"body":"but he was found instead to have ileitis"},{"startTime":105.8,"endTime":107.72,"body":"and mesenteric adenitis."},{"startTime":107.72,"endTime":109.43,"body":"[Dr. Wiener] Right, and"},{"startTime":107.72,"endTime":109.43,"body":"presumably this is acute,"},{"startTime":109.43,"endTime":111.76,"body":"we're not given any non-infectious causes,"},{"startTime":111.76,"endTime":114.0,"body":"such as Crohn's disease in the options."},{"startTime":114.0,"endTime":116.4,"body":"So which of the infections"},{"startTime":114.0,"endTime":116.4,"body":"are you thinking of?"},{"startTime":116.4,"endTime":117.945,"body":"[Dr. Handy] All right, well,"},{"startTime":116.4,"endTime":117.945,"body":"the answer choices are all"},{"startTime":117.945,"endTime":120.68,"body":"infections, and what we"},{"startTime":117.945,"endTime":120.68,"body":"have here is an example"},{"startTime":120.68,"endTime":122.23,"body":"of pseudo appendicitis."},{"startTime":122.23,"endTime":124.963,"body":"So of the choices listed,"},{"startTime":122.23,"endTime":124.963,"body":"this is typically associated"},{"startTime":124.963,"endTime":127.22,"body":"with Yersinia enterocolitica infection,"},{"startTime":127.22,"endTime":128.95,"body":"so the answer would be E."},{"startTime":128.95,"endTime":130.004,"body":"[Dr. Wiener] All right,"},{"startTime":128.95,"endTime":130.004,"body":"well, you're going to have to"},{"startTime":130.004,"endTime":131.035,"body":"tell me more about that."},{"startTime":131.035,"endTime":133.61,"body":"[Dr. Handy chuckles] Yersinia"},{"startTime":131.035,"endTime":133.61,"body":"enterocolitica infection"},{"startTime":133.61,"endTime":135.395,"body":"typically causes terminal ileitis"},{"startTime":135.395,"endTime":139.2,"body":"and adenitis as was"},{"startTime":135.395,"endTime":139.2,"body":"presented in this patient."},{"startTime":139.2,"endTime":141.58,"body":"It's transmitted from"},{"startTime":139.2,"endTime":141.58,"body":"inadequately cooked pork"},{"startTime":141.58,"endTime":144.36,"body":"or contaminated meats,"},{"startTime":141.58,"endTime":144.36,"body":"milk, or even vegetables."},{"startTime":144.36,"endTime":146.8,"body":"A high percentage of pigs carry pathogenic"},{"startTime":146.8,"endTime":149.09,"body":"Yersinia enterocolitica and their feces"},{"startTime":149.09,"endTime":150.57,"body":"can contaminate other animals"},{"startTime":150.57,"endTime":153.48,"body":"because the organism can"},{"startTime":150.57,"endTime":153.48,"body":"colonize many species."},{"startTime":153.48,"endTime":155.48,"body":"The organism also can live in water,"},{"startTime":155.48,"endTime":158.89,"body":"so ingestion of contaminated"},{"startTime":155.48,"endTime":158.89,"body":"water may cause disease."},{"startTime":158.89,"endTime":160.47,"body":"Symptoms are typically diarrhea,"},{"startTime":160.47,"endTime":162.86,"body":"which may be bloody and also fever."},{"startTime":162.86,"endTime":166.12,"body":"It's typically self-limited,"},{"startTime":162.86,"endTime":166.12,"body":"and if endoscopy is performed,"},{"startTime":166.12,"endTime":167.71,"body":"you see thickening and ulcerations"},{"startTime":167.71,"endTime":169.56,"body":"of the terminal ileum and cecum,"},{"startTime":169.56,"endTime":171.58,"body":"with elevated round or oval lesions"},{"startTime":171.58,"endTime":173.79,"body":"that can overlay the Peyer patches."},{"startTime":173.79,"endTime":176.68,"body":"Radiographically, mesenteric"},{"startTime":173.79,"endTime":176.68,"body":"lymph nodes are enlarged."},{"startTime":176.68,"endTime":178.2,"body":"[Dr. Wiener] Does this"},{"startTime":176.68,"endTime":178.2,"body":"infection cause sepsis"},{"startTime":178.2,"endTime":180.1,"body":"or other complications?"},{"startTime":180.1,"endTime":182.045,"body":"[Dr. Handy] Septicemia is"},{"startTime":180.1,"endTime":182.045,"body":"more likely in patients"},{"startTime":182.045,"endTime":185.04,"body":"with preexisting conditions,"},{"startTime":182.045,"endTime":185.04,"body":"such as diabetes mellitus,"},{"startTime":185.04,"endTime":189.1,"body":"liver disease, advanced age,"},{"startTime":185.04,"endTime":189.1,"body":"malignancy, or HIV/AIDS."},{"startTime":189.1,"endTime":192.1,"body":"Interestingly, Yersinia are"},{"startTime":189.1,"endTime":192.1,"body":"among the iron loving bacteria,"},{"startTime":192.1,"endTime":195.28,"body":"so patients with any condition"},{"startTime":192.1,"endTime":195.28,"body":"involving iron overload,"},{"startTime":195.28,"endTime":197.56,"body":"such as hemochromatosis and thalassemia"},{"startTime":197.56,"endTime":200.47,"body":"are also at higher risk of severe disease."},{"startTime":200.47,"endTime":203.21,"body":"As in enteritis of other"},{"startTime":200.47,"endTime":203.21,"body":"bacterial etiologies,"},{"startTime":203.21,"endTime":204.95,"body":"post infective complications,"},{"startTime":204.95,"endTime":207.13,"body":"such as reactive arthritis occur mainly"},{"startTime":207.13,"endTime":210.44,"body":"in individuals who are HLA-B27 positive."},{"startTime":210.44,"endTime":212.25,"body":"[Dr. Wiener] You mentioned"},{"startTime":210.44,"endTime":212.25,"body":"that the Yersinia infection"},{"startTime":212.25,"endTime":215.542,"body":"is typically self-limited."},{"startTime":212.25,"endTime":215.542,"body":"Does it require any treatment?"},{"startTime":215.542,"endTime":217.34,"body":"[Dr. Handy] Data from"},{"startTime":215.542,"endTime":217.34,"body":"clinical trials do not support"},{"startTime":217.34,"endTime":220.003,"body":"antimicrobial treatment"},{"startTime":217.34,"endTime":220.003,"body":"for adults or children"},{"startTime":220.003,"endTime":222.7,"body":"with Yersinia enterocolitica diarrhea."},{"startTime":222.7,"endTime":224.7,"body":"Systemic infections with bacteremia"},{"startTime":224.7,"endTime":226.54,"body":"or focal infections outside"},{"startTime":226.54,"endTime":228.32,"body":"the gastrointestinal tract generally"},{"startTime":228.32,"endTime":230.77,"body":"do require antimicrobial therapy."},{"startTime":230.77,"endTime":232.36,"body":"Yersinia enterocolitica strains"},{"startTime":232.36,"endTime":234.7,"body":"nearly always express beta-lactamases,"},{"startTime":234.7,"endTime":238.483,"body":"and because of the relative"},{"startTime":234.7,"endTime":238.483,"body":"rarity of systemic infections,"},{"startTime":238.483,"endTime":239.81,"body":"there are no clinical trial data"},{"startTime":239.81,"endTime":241.39,"body":"to guide antimicrobial choice"},{"startTime":241.39,"endTime":244.532,"body":"or to suggest the optimal"},{"startTime":241.39,"endTime":244.532,"body":"dose and duration of therapy,"},{"startTime":244.532,"endTime":246.83,"body":"but on the basis of"},{"startTime":244.532,"endTime":246.83,"body":"retrospective case studies"},{"startTime":246.83,"endTime":248.8,"body":"and in vitro sensitivity data,"},{"startTime":248.8,"endTime":250.64,"body":"fluoroquinolone therapy is effective"},{"startTime":250.64,"endTime":252.49,"body":"for bacteremia in adults."},{"startTime":252.49,"endTime":254.4,"body":"A third-generation cephalosporin"},{"startTime":254.4,"endTime":256.7,"body":"is also a reasonable alternative."},{"startTime":256.7,"endTime":259.4,"body":"Amoxicillin and amoxicillin / clavulanic"},{"startTime":259.4,"endTime":261.56,"body":"have shown poor efficacy in case series,"},{"startTime":261.56,"endTime":263.127,"body":"so I wouldn't recommend those."},{"startTime":263.127,"endTime":266.671,"body":"Trimethoprim /"},{"startTime":263.127,"endTime":266.671,"body":"sulfamethoxazole, gentamycin,"},{"startTime":266.671,"endTime":269.65,"body":"and imipenem are all also active in vitro."},{"startTime":269.65,"endTime":271.41,"body":"[Dr. Wiener] Great, so what"},{"startTime":269.65,"endTime":271.41,"body":"about the other choices?"},{"startTime":271.41,"endTime":272.93,"body":"Any comments on those?"},{"startTime":272.93,"endTime":275.27,"body":"[Dr. Handy] Sure. Trichinella"},{"startTime":272.93,"endTime":275.27,"body":"is classically associated"},{"startTime":275.27,"endTime":277.38,"body":"with consuming undercooked pork products,"},{"startTime":277.38,"endTime":279.71,"body":"but is associated with"},{"startTime":277.38,"endTime":279.71,"body":"neuromuscular damage"},{"startTime":279.71,"endTime":281.092,"body":"and inflammation as opposed to"},{"startTime":281.092,"endTime":283.81,"body":"terminal ileitis or pseudo appendicitis."},{"startTime":283.81,"endTime":286.28,"body":"In fact, trichinosis"},{"startTime":283.81,"endTime":286.28,"body":"is remarkably uncommon"},{"startTime":286.28,"endTime":288.18,"body":"in the U. S. from commercial pork."},{"startTime":288.18,"endTime":289.37,"body":"You're more likely to get it"},{"startTime":289.37,"endTime":291.57,"body":"from undercooked wilds or game meat."},{"startTime":291.57,"endTime":293.88,"body":"Clostridium difficile causes a colitis"},{"startTime":293.88,"endTime":295.9,"body":"and E. coli can cause enteritis,"},{"startTime":295.9,"endTime":297.51,"body":"although not classically associated"},{"startTime":297.51,"endTime":300.11,"body":"with terminal ileitis and adenitis."},{"startTime":300.11,"endTime":301.82,"body":"And I'll just add, not listed here,"},{"startTime":301.82,"endTime":304.46,"body":"but Campylobacter jejuni"},{"startTime":301.82,"endTime":304.46,"body":"is the other infection"},{"startTime":304.46,"endTime":307.15,"body":"that is associated with"},{"startTime":304.46,"endTime":307.15,"body":"pseudo appendicitis."},{"startTime":307.15,"endTime":308.39,"body":"[Dr. Wiener] Okay, thanks."},{"startTime":308.39,"endTime":310.36,"body":"So the teaching points in this case"},{"startTime":310.36,"endTime":312.84,"body":"are that Yersinia enterocolitica infection"},{"startTime":312.84,"endTime":314.65,"body":"is the cause of pseudo appendicitis"},{"startTime":314.65,"endTime":316.23,"body":"in adolescents and adults"},{"startTime":316.23,"endTime":318.53,"body":"and it may arise from contaminated food."},{"startTime":318.53,"endTime":320.06,"body":"It typically causes diarrhea"},{"startTime":320.06,"endTime":322.61,"body":"with ileitis and mesenteric adenitis."},{"startTime":322.61,"endTime":324.28,"body":"The infection typically does not require"},{"startTime":324.28,"endTime":326.9,"body":"antibiotic therapy"},{"startTime":324.28,"endTime":326.9,"body":"except for in susceptible"},{"startTime":326.9,"endTime":328.94,"body":"or bacteremic individuals."},{"startTime":328.94,"endTime":330.11,"body":"[Dr. Handy] And you can"},{"startTime":328.94,"endTime":330.11,"body":"read more about this"},{"startTime":330.11,"endTime":331.87,"body":"in Harrison's chapter on the plague"},{"startTime":331.87,"endTime":333.805,"body":"and other Yersenia infections."},{"startTime":333.805,"endTime":338.213,"body":"[upbeat outro music]"},{"startTime":338.213,"endTime":341.07,"body":"[Mr. Shanahan] This is Jim"},{"startTime":338.213,"endTime":341.07,"body":"Shanahan, publisher at McGraw Hill."},{"startTime":341.07,"endTime":342.69,"body":"Harrison's PodClass is brought to you"},{"startTime":342.69,"endTime":344.68,"body":"by McGraw Hill's AccessMedicine,"},{"startTime":344.68,"endTime":346.77,"body":"the online medical resource that delivers"},{"startTime":346.77,"endTime":350.0,"body":"the latest trusted content from"},{"startTime":346.77,"endTime":350.0,"body":"the best minds in medicine."},{"startTime":350.0,"endTime":352.563,"body":"Go to accessmedicine.com to learn more."}]}