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Kingella kingae pneumonia: a rare pathology or a pathology rarely diagnosed?
Case Report
Kkzgella kivtgae Pneumonia: A Rare Pathology or a Pathology Rarely Diagnosed? Jose-Luis Gomez-Garces, M.D., Ph.D. Jesus Oteo, M.D. Guadalupe Garcia, M.S. Juan-Ignacio Alos, Pharm.D., Ph.D. Senicio
de Microhiologia
Hospitnl de Mostoles M0.srole.s28935. Madrid Spoiti
Kingella kingae, a fastidious gramnegative coccobacillus, has been considered a rare cause of human infections (1). In the last decade, improved isolation techniques and a growing knowledge of the organism have revealed that K. kingae is a relatively common cause of bacteremia and septic arthritis in children under 2 years of age (2,3). However, despite the increasing recognition of K. kingae as an important pathogen in this age group and the high percentage of children colonized in the upper respiratory tract by this organism (4) there are very few cases of K. kingae pneumonia reported in the literature. We describe a case of K. kingae bacteremjc pneumonia in a 1O-year-old girl treated in our hospital.
zone of beta-hemolysis in blood agar was observed after 72 h. The microorganism was oxidase positive, catalase negative, unable to grow on MacConkey agar, urease and indole negative, and produced acid from glucose and, after 72 h, from maltose. It was, therefore, identified as K. kingae (Table 1). The strain displayed susceptibility by agar disk diffusion to ampicillin, cefazolin, cefotaxime, imipenem, gentamicin, and ciprofloxacin. In view of the results, it was decided to change treatment to intravenous cefotaxime for 6 days. The patient’s condition showed clinical and radiological improvement, and she was asymptomatic when she left the hospital 10 days after admission. Treatment with oral amoxicillin/clavulanic acid was continued for an additional 6 days.
Discussion K. kingae is a slow-growing, gramnegative coccobacillus that is part of the
Table 1. Phenotypic characteristics
Case Report
Test
A previously healthy 1O-year-old girl who presented with a clinical picture of sore throat, cough, purulent sputum, and fever of 39.8”C was seen in our Pediatric Service, where tracheobronchitis was diagnosed. Empiric treatment with amoxicillin (250 mgi8 h) was prescribed, and the child was sent home. After a slight improvement, fever reappeared, the cough worsened, and she was admitted to the hospital. Pulmonary examination revealed rhonchi and rales and a chest X ray showed condensation in the right lower lobe. Blood cultures were taken before commencing treatment with amoxiciliin/clavulanic acid. At 72 h, growth of a gram-negative coccobacillus, arranged in pairs and in short chains, was observed in the aerobic bottles. On subculture to blood and chocolate agar plates, incubated with 5% CO, at 37”C, growth of smooth, convex, whitish colonies with a narrow
Morphology
I 02
0196.4399 on (see frontmatter)
human oropharyngeal flora (5). Like other microorganisms that share this habitat, it has been implicated in invasive infections in small children, mainly bone and joint infections (3,6), although cases of bacteremia, endocarditis, and meningitis have been reported (7-10). In recent years, automated blood culture methods have contributed to the isolation of this microorganism, not only from blood but also from other normally sterile body fluids, particulary joint fluid. In 1992, Yagupsky et al. (11) reported the isolation of K. kingae in 11% of cases of septic arthritis studied. Of these, 90% of strains could be recovered only by means of automated blood culture systems and not by traditional culture. K. kingae frequently colonizes the respiratory tract of children under 2 years of age, to the extent that it may be considered simply another member of the normal flora of this area. In a prospective study published in 1995,
of Kingella kingae Results Gram-negative
coccobacillus
Capnophilic
+
Beta-hemolysis
+
Oxidase
+
Catalase
_
Lysine decarboxylase
-
Omithine decarboxylase
-
lndole
_
Urease
_
Esculin hydrolysis
_
Acid from: Glucose
(+I
Maltose
(+I
Sucrose
-
MacConkey, growth
_
MTM
+
“Delayed
medium, growth reaction
6’) 2001
Elsevier
Science
Inc.
Clinical
Microbiology
Newsletter
23:24.2001
Yagupsky et al. (4) isolated K. kingue from 109 of 624 pharyngeal exudates from children treated in a day-care center. In 1998, Slonin et al. (12) demonstrated that person-to-person transmission was the most probable means of colonization in children attending a nursery school because most of these isolates belonged to only two molecular types. In the same study, the microorganism was not isolated from any cultures from the adult personnel of the center. This confirms the rarity of invasive infections in adults, in whom, with rare exceptions, the infection is associated with some type of immunosuppression. The organism probably invades the bloodstream by means of breaks in the mucous membranes of the upper respiratory tract, after a prior viral infection, or as a result of erosions in the oral mucous membrane. The lack of reports of pneumonia caused by K. kingae may be due to the infrequency of bacteremia produced and the difficulty in recovering K. kingae from culture of respiratory secretions. Difficulty in obtaining a good respiratory specimen from children and the morphological similarity to other oropharyngeal inhabitants (MoraxeIla catarrhalis and Neisseria spp.) seen in the Gram stain creates diagnostic difficulties in the majority of cases. On the other hand, K. kingue is usually susceptible to a large number of antimicrobial agents widely used in the
Clinical Microbiology
Newsher
23:24,2001
empiric treatment of respiratory infections, In a recent series, Yagupsky et al. (13) found no p-lactamase producing strains in 142 isolates of K. kingae with MIC,, for penicillin of 0.047 mg/liter. All the isolates also showed susceptibility to erythromycin, gentamicin, ciprofloxacin, and tetracycline, among others, so it is not surprising that empiric treatment before microbiological diagnosis makes it difficult to isolate the organism. K. kingue appears to be a pediatric pathogen of growing importance which should be considered more often in infections other than osteoarticular infections in this age group.
P. Murray et al. (ed.), Manual of clinical microbiology,
th ed. ASM Press,
Washington, D.C. 6. Luhmann, J.D. and S.J. Luhmann. 1999. Etiology of septic arthritis in children: an update for the 1990s. Pediatr. Emerg. Care 1540-42. 7. Lewis, M.B. and J.M. Bamford. 2000. Global aphasia without hemiparesis secondary to Kingella kingae endocarditis. Arch. Neurol. 57: 1774-I 775. 8. Wolak, T. et al. 2000. Kingella endocarditis and meningitis in a patient with SLE and associated antiphospholipid syndrome. Lupus 9:393-396. 9. Birginsson, H., 0. Steingrimsson, and T. Gudnason. 1997. Kingella kingae endocarditis following chickenpox in
References
infancy. Eur. J. Clin. Microbial.
1985. Kingella kingae infections: a
10. Roiz, M.P., F.G. Peralta, and R. Arjona.
review and a presentation of data from
1997. Kingella kingae bacteremia in an
10 Swedish cases. Stand. J. Infect. Dis. 17:233-243.
immunocompetent
2. Moylett, E.H. et al. 2000. Importance of
3.
Infect.
Dis. 16:944-946.
1. Claesson, B., E. Falsen, and B. Kjellman.
Microbial. II.
adult host. J. Clin.
35: 1916.
Yagupsky, P. et al. 1992. High preva-
Kingella kingae as a pediatric pathogen
lence of Kingella kingae in joint fluid
in the United States. Pediatr. Infect. Dis. J. 19:263-265.
from children with septic arthritis revealed by the BACTEC
Yagupsky, R and R. Dagan. 1997.
system. J. Clin. Microbial.
Kingella kingae: an emerging cause of
1281.
invasive infections in young children.
blood culture 30: 127%
12. Slonin, A. et al. 1998. Person-to-person
Clin. Infect. Dis. 24:860-866.
transmission of Kingella kingae among
Yagupsky, P et al. 1995. Respiratory
day care center attendees. J. Infect. Dis.
carriage of Kingella kingae among healthy children. Pediatr. Infect. Dis. J.
178: 1843-I 846. 13. Yagupsky, P., 0. Katz, and N. Peled.
14:673-678.
2001. Antibiotic susceptibility of
Mutter, R. 1999. Actinobacillus, Capno-
Kingella kingae isolates from respira-
cytophaga. Eikenella, Kingella. and
tory carriers and patients with invasive
other fastidious or rarely encountered gram-negative rods, p. 561-571. In
infections. J. Antimicrob.
0 2001 Elsevier Science Inc.
Chemother.
47:191-193.
0196-4399/00
(see frontmatter)
193
Kkzgella kivtgae Pneumonia: A Rare Pathology or a Pathology Rarely Diagnosed? Jose-Luis Gomez-Garces, M.D., Ph.D. Jesus Oteo, M.D. Guadalupe Garcia, M.S. Juan-Ignacio Alos, Pharm.D., Ph.D. Senicio
de Microhiologia
Hospitnl de Mostoles M0.srole.s28935. Madrid Spoiti
Kingella kingae, a fastidious gramnegative coccobacillus, has been considered a rare cause of human infections (1). In the last decade, improved isolation techniques and a growing knowledge of the organism have revealed that K. kingae is a relatively common cause of bacteremia and septic arthritis in children under 2 years of age (2,3). However, despite the increasing recognition of K. kingae as an important pathogen in this age group and the high percentage of children colonized in the upper respiratory tract by this organism (4) there are very few cases of K. kingae pneumonia reported in the literature. We describe a case of K. kingae bacteremjc pneumonia in a 1O-year-old girl treated in our hospital.
zone of beta-hemolysis in blood agar was observed after 72 h. The microorganism was oxidase positive, catalase negative, unable to grow on MacConkey agar, urease and indole negative, and produced acid from glucose and, after 72 h, from maltose. It was, therefore, identified as K. kingae (Table 1). The strain displayed susceptibility by agar disk diffusion to ampicillin, cefazolin, cefotaxime, imipenem, gentamicin, and ciprofloxacin. In view of the results, it was decided to change treatment to intravenous cefotaxime for 6 days. The patient’s condition showed clinical and radiological improvement, and she was asymptomatic when she left the hospital 10 days after admission. Treatment with oral amoxicillin/clavulanic acid was continued for an additional 6 days.
Discussion K. kingae is a slow-growing, gramnegative coccobacillus that is part of the
Table 1. Phenotypic characteristics
Case Report
Test
A previously healthy 1O-year-old girl who presented with a clinical picture of sore throat, cough, purulent sputum, and fever of 39.8”C was seen in our Pediatric Service, where tracheobronchitis was diagnosed. Empiric treatment with amoxicillin (250 mgi8 h) was prescribed, and the child was sent home. After a slight improvement, fever reappeared, the cough worsened, and she was admitted to the hospital. Pulmonary examination revealed rhonchi and rales and a chest X ray showed condensation in the right lower lobe. Blood cultures were taken before commencing treatment with amoxiciliin/clavulanic acid. At 72 h, growth of a gram-negative coccobacillus, arranged in pairs and in short chains, was observed in the aerobic bottles. On subculture to blood and chocolate agar plates, incubated with 5% CO, at 37”C, growth of smooth, convex, whitish colonies with a narrow
Morphology
I 02
0196.4399 on (see frontmatter)
human oropharyngeal flora (5). Like other microorganisms that share this habitat, it has been implicated in invasive infections in small children, mainly bone and joint infections (3,6), although cases of bacteremia, endocarditis, and meningitis have been reported (7-10). In recent years, automated blood culture methods have contributed to the isolation of this microorganism, not only from blood but also from other normally sterile body fluids, particulary joint fluid. In 1992, Yagupsky et al. (11) reported the isolation of K. kingae in 11% of cases of septic arthritis studied. Of these, 90% of strains could be recovered only by means of automated blood culture systems and not by traditional culture. K. kingae frequently colonizes the respiratory tract of children under 2 years of age, to the extent that it may be considered simply another member of the normal flora of this area. In a prospective study published in 1995,
of Kingella kingae Results Gram-negative
coccobacillus
Capnophilic
+
Beta-hemolysis
+
Oxidase
+
Catalase
_
Lysine decarboxylase
-
Omithine decarboxylase
-
lndole
_
Urease
_
Esculin hydrolysis
_
Acid from: Glucose
(+I
Maltose
(+I
Sucrose
-
MacConkey, growth
_
MTM
+
“Delayed
medium, growth reaction
6’) 2001
Elsevier
Science
Inc.
Clinical
Microbiology
Newsletter
23:24.2001
Yagupsky et al. (4) isolated K. kingue from 109 of 624 pharyngeal exudates from children treated in a day-care center. In 1998, Slonin et al. (12) demonstrated that person-to-person transmission was the most probable means of colonization in children attending a nursery school because most of these isolates belonged to only two molecular types. In the same study, the microorganism was not isolated from any cultures from the adult personnel of the center. This confirms the rarity of invasive infections in adults, in whom, with rare exceptions, the infection is associated with some type of immunosuppression. The organism probably invades the bloodstream by means of breaks in the mucous membranes of the upper respiratory tract, after a prior viral infection, or as a result of erosions in the oral mucous membrane. The lack of reports of pneumonia caused by K. kingae may be due to the infrequency of bacteremia produced and the difficulty in recovering K. kingae from culture of respiratory secretions. Difficulty in obtaining a good respiratory specimen from children and the morphological similarity to other oropharyngeal inhabitants (MoraxeIla catarrhalis and Neisseria spp.) seen in the Gram stain creates diagnostic difficulties in the majority of cases. On the other hand, K. kingue is usually susceptible to a large number of antimicrobial agents widely used in the
Clinical Microbiology
Newsher
23:24,2001
empiric treatment of respiratory infections, In a recent series, Yagupsky et al. (13) found no p-lactamase producing strains in 142 isolates of K. kingae with MIC,, for penicillin of 0.047 mg/liter. All the isolates also showed susceptibility to erythromycin, gentamicin, ciprofloxacin, and tetracycline, among others, so it is not surprising that empiric treatment before microbiological diagnosis makes it difficult to isolate the organism. K. kingue appears to be a pediatric pathogen of growing importance which should be considered more often in infections other than osteoarticular infections in this age group.
P. Murray et al. (ed.), Manual of clinical microbiology,
th ed. ASM Press,
Washington, D.C. 6. Luhmann, J.D. and S.J. Luhmann. 1999. Etiology of septic arthritis in children: an update for the 1990s. Pediatr. Emerg. Care 1540-42. 7. Lewis, M.B. and J.M. Bamford. 2000. Global aphasia without hemiparesis secondary to Kingella kingae endocarditis. Arch. Neurol. 57: 1774-I 775. 8. Wolak, T. et al. 2000. Kingella endocarditis and meningitis in a patient with SLE and associated antiphospholipid syndrome. Lupus 9:393-396. 9. Birginsson, H., 0. Steingrimsson, and T. Gudnason. 1997. Kingella kingae endocarditis following chickenpox in
References
infancy. Eur. J. Clin. Microbial.
1985. Kingella kingae infections: a
10. Roiz, M.P., F.G. Peralta, and R. Arjona.
review and a presentation of data from
1997. Kingella kingae bacteremia in an
10 Swedish cases. Stand. J. Infect. Dis. 17:233-243.
immunocompetent
2. Moylett, E.H. et al. 2000. Importance of
3.
Infect.
Dis. 16:944-946.
1. Claesson, B., E. Falsen, and B. Kjellman.
Microbial. II.
adult host. J. Clin.
35: 1916.
Yagupsky, P. et al. 1992. High preva-
Kingella kingae as a pediatric pathogen
lence of Kingella kingae in joint fluid
in the United States. Pediatr. Infect. Dis. J. 19:263-265.
from children with septic arthritis revealed by the BACTEC
Yagupsky, R and R. Dagan. 1997.
system. J. Clin. Microbial.
Kingella kingae: an emerging cause of
1281.
invasive infections in young children.
blood culture 30: 127%
12. Slonin, A. et al. 1998. Person-to-person
Clin. Infect. Dis. 24:860-866.
transmission of Kingella kingae among
Yagupsky, P et al. 1995. Respiratory
day care center attendees. J. Infect. Dis.
carriage of Kingella kingae among healthy children. Pediatr. Infect. Dis. J.
178: 1843-I 846. 13. Yagupsky, P., 0. Katz, and N. Peled.
14:673-678.
2001. Antibiotic susceptibility of
Mutter, R. 1999. Actinobacillus, Capno-
Kingella kingae isolates from respira-
cytophaga. Eikenella, Kingella. and
tory carriers and patients with invasive
other fastidious or rarely encountered gram-negative rods, p. 561-571. In
infections. J. Antimicrob.
0 2001 Elsevier Science Inc.
Chemother.
47:191-193.
0196-4399/00
(see frontmatter)
193