Bilateral Femoral Arteritis Associated With Yersinia Enterocolitica in a 12-Year-old Girl

To the Editors: A 12-year-old girl presented with a fever 4 days after eating barbeque with her family. Eight days later, she developed diarrhea and abdominal pain. She visited her family doctor and was prescribed clarithromycin. The fever resolved, and the abdominal pain and diarrhea improved. Sixteen days after symptom onset, she complained of bilateral thigh pain and visited her local orthopedic surgeon. Magnetic resonance imaging (MRI) revealed high T2-weighted imaging and short tau inversion recovery signals in the bilateral femoral arteries extending to the popliteal artery (Fig. 1A). The patient was then referred to our hospital.FIGURE 1.: Imaging findings. A: Magnetic resonance imaging (MRI) with T2-weighted imaging (T2WI) showing high signal intensity in the bilateral femoral arteries extending to the popliteal arteries (white arrow). B,C: Ultrasonography demonstrating left femoral artery wall thickening (white arrow) and enlarged iliac peritoneal lymph nodes (white arrow). D: Follow-up MRI at 3 months after treatment completion showing disappearance of T2W1 high signal intensity (white arrow). E: Follow-up ultrasonography showing normalization of the left femoral artery wall thickness (white arrow).She had a fever of 38 °C, ocular conjunctival hyperemia, lip redness, tenderness of bilateral cervical lymph nodes, left scapuloclavicular joint pain and right wrist joint pain. Ultrasonography revealed bilateral femoral artery wall thickening and enlarged iliac peritoneal lymph nodes (Fig. 1B,C). Laboratory findings showed an elevated white blood cell count of 11,200/µL with neutrophilia (64%) and C-reactive protein of 8.3 mg/dL. Treatment with cefotaxime was initiated, resulting in the resolution of her fever, bilateral thigh pain, and other Kawasaki disease-like symptoms. After a 7-day course of cefotaxime, her white blood cell count decreased to 7900/μL and C-reactive protein decreased to 0.8 mg/dL. Although no bacteria were detected in her blood cultures, Yersinia enterocolitica (serogroup O:8) was detected in stool cultures. Follow-up MRI and ultrasonography performed 3 months later showed normalization (Fig. 1D,E). Contrast-enhanced computed tomography revealed no arterial aneurysms, including those of the abdominal aorta. Eleven months after completing treatment, she remained asymptomatic. The most noteworthy finding, in this case, is the development of Y. enterocolitica-associated femoral arteritis in a child. Pile et al1 reported a case of Y. enterocolitica-related polyarteritis in a 43-year-old man.1 In that report, Y. enterocolitica antigens were detected in the walls of small arteries. Similarly, Rodio et al2. reported a case of abdominal aortic aneurysm due to Y. enterocolitica in a 63-year-old man. They speculated that Y. enterocolitica translocated into the aneurysm via the inflammatory process of the small intestine. Additionally, they summarized 21 other cases of infected aneurysms due to Y. enterocolitica.2 These case reports indicated that Y. enterocolitica can cause infected arteritis in adults. Our case report is the first to suggest that Y. enterocolitica can cause infectious arteritis in children. Another aspect of this case is the presence of Kawasaki disease-like symptoms. Feeney et al3 reported 2 cases of Kawasaki disease associated with Y. enterocolitica, 1 case was treated with ceftriaxone and metronidazole, and the other case was treated with trimethoprim-sulfamethoxazole. Similarly, Ohnishi et al4 reported a case where cefotaxime proved effective for Y. enterocolitica-associated Kawasaki disease treatment, while intravenous immunoglobulin was ineffective. Notably, Ohnishi et al4 emphasized the importance of terminal ileitis with mesenteric lymph node enlargement in Kawasaki disease-like illness due to Y. enterocolitica,4 which aligns with the enlarged intestinal lymph nodes observed in our patient. In conclusion, this case highlights the potential of Y. enterocolitica to cause femoral arteritis in addition to Kawasaki disease-like symptoms in children.