Two Atypical Cases of Kingella kingae Invasive Infection with Concomitant Human Rhinovirus Infection

Abstract

eWe describe two atypical cases of Kingella kingae infection in children diagnosed by PCR, one case involving a soft tissue abscess and one case a femoral Brodie abscess. Both patients had concomitant human rhinovirus infection. K. kingae strains, isolated from an oropharyngeal swab, were characterized by multilocus sequence typing and rtxA sequencing. CASE REPORTSP atient 1 was a healthy 14-month-old girl who was admitted to our tertiary care center because mobilization of her elbow had been painful for 2 days, and an induration of the superior anterior side of her arm was noted, without skin redness. She presented with a 5-day history of febrile viral upper respiratory tract (URT) infection with a maximal temperature of 39.7°C. A biologic inflammatory syndrome was noted, with 14,400 leukocytes/mm 3 , 574,000 platelets/mm 3 , 5.36 g/liter of fibrinogen (normal value, 2 to 4 g/liter), and a C-reactive protein (CRP) level of 47 mg/liter (normal value, 0 to 10 mg/liter). X-ray analysis and ultrasonography of the left upper arm were performed, but neither bone lesion, subperiostal abscess (Fig. 1a), nor joint effusion was reported. However, a soft tissue collection with a hypoechogenic center measuring 22 mm by 5 mm was identified in the anterior muscular compartment of the left arm (Fig. 1b). Surgery was performed for debridement before treatment with antibiotics. Blood cultures, as well as the aerobic and anaerobic cultures of the purulent collection, were sterile, despite inoculation into blood culture vials, but Kingella kingae-specific real-time PCR (1) gave positive results in the abscess. In addition, K. kingae was isolated from an oropharyngeal swab, as previously described (2). The isolated strain was susceptible to amoxicillin and cefamandole but resistant to nalidixic acid and lincomycin, as determined by the disc diffusion method (3). Intravenous antibiotic therapy was therefore initiated immediately after bacteriological sampling, with cefamandole (140 mg/kg of body weight/day) for 5 days. The postoperative evolution was favorable, with no more fever and no more pain during mobilization of the upper limb. On day 3, the biologic inflammatory syndrome decreased; the leukocyte count was 8,200 cells/mm 3 , the fibrinogen level was 4.32 g/liter, and the CRP level was 10 mg/liter. She was discharged on day 5 and given oral antibiotic therapy with amoxicillin (100 mg/kg/day) for 5 more days. Her clinical and biologic features were still normal 3 months later at the control examination.With the use of multilocus sequence typing (MLST) analysis (4), the K. kingae isolate was shown to belong to sequence type 14 (ST14) and to harbor rtxA14 of hemolytic RTX toxin. Unfortunately, because of the low DNA load in the abscess sample and the length of the MLST genes, we failed to amplify all six MLST genes directly on the DNA extract of the abscess. However, three genes (aroE, cpn60, and recA) were successfully studied and displayed the same alleles as those of the oropharyngeal strain. These partial results emphasized ...

Kingella kingae: Carriage, Transmission, and Disease

“…In two recent reports, K. kingae organisms belonging to ST-25 were found to be strongly associated with childhood osteomyelitis, causing a cluster of 4 bone infections among 5 affected day care attendees (98) and later an additional sporadic case (111), and an ST-6 strain caused a cluster of 3 cases of osteomyelitis in an Israeli day care center (112). These observations imply that carriage of particular strains entails increased risk for clinical disease and invasion of specific body tissues.…”

“…In a recent report, Basmaci et al strengthened the link between invasive K. kingae disease and viral upper respiratory tract comorbidity by detecting rhinoviruses in two children with concomitant PCRproven K. kingae infections of bone and soft tissues (111).…”

“…Detection of the causative organism has been performed by culture of the aspirated exudate (171,199,200,215,225,227), by a blood culture (171,185,223), or by an NAA assay (111,200,224).…”

<p>Systematic Review of <em>Kingella kingae</em> Musculoskeletal Infection in Children: Epidemiology, Impact and Management Strategies</p>

“…Additional epidemiological data extracted and collated included musculoskeletal infection sites, gender, age and seasonality. Twenty-one articles reported on clinical findings (Table 3) 4,7,35,36,39,41,[51][52][53][54][55][56][57][58][59][60][61][62][63][64]71 and fourteen articles reported on the impact or outcome as well as management strategies (…”

Brodie abscess of the femoral capital epiphysis in a 2-year-old child caused byKingella kingae

“…In our search of the literature, we noted two case reports and a case series presenting K. kingae invasive infections causing osteomyelitis involving the epiphysis,8–10 and also two case reports presenting K. kingae causing a Brodie abscess’ one involving the proximal tibia,6 and the other, the distal femur 11…”