Letters to the Editor Hand, Foot and Mouth Disease and Kingella kingae Infections To the Editors: and, foot and mouth disease (HFMD) is a childhood disease caused by human enteroviruses that affects particularly toddlers in the age of 6–23 months.1 HFMD is usually associated with benign and self-resolving aphthous ulcers and skin rash of the extremities that occur as epidemic waves in summer and in early fall, but also all year around as sporadic cases. Uncommonly, it leads to meningoencephalitis and cardiopulmonary complications. To our knowledge, osteoarticular infections secondary to HFMD have not been yet documented. Herein, we report a series of children who developed Kingella kingae infections following HFMD. From April to October 2013, 9 children ranging from 10 to 45 months old (mean age: 18.7 months) were diagnosed with K. kingae osteoarticular infections in the Department of Pediatric Orthopedics of the University La Timone Children’s Hospital, Marseille, France. Four cases were epidemic, and 5 were sporadic. Real-time PCR targeting the cpn60 gene of K. kingae was positive from osteoarticular samples (6/8), blood (1/8), and oropharynx (6/8),2 and K. kingae was also cultivated from peripheral blood in 1 case (Table 1). Among toddlers younger than 24 months (7/9), 5 presented with HFMD (71.4%) in the prior 3 weeks, and 2 with stomatitis (28.6%) leading to a painful mouth and feeding difficulties. No oral manifestations were found in the 2 children >23 months old. During the same period, the National Reference Center for Enteroviruses and Parechoviruses (CNREV-PEV) in Clermont-Ferrand, France, noticed an increased incidence of HFMD. We retrospectively analyzed joint aspirations harvested from an 11 month-old girl who presented with arthritis secondary to HFMD, in whom first analysis performed by routine methods of cultures failed to detect bacteria. Joint aspirations and stool specimens were sent to the CNREV-PEV, and coxsackievirus-A6 infection was confirmed by enterovirus genome detection and genotyping

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The work was funded by the Méditérannée Infection foundation. The manuscript has not been submitted elsewhere nor previously published. The authors have no other funding or conflicts of interest to disclose. Address for Correspondence: Nawal El Houmami, MD; E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved ISSN: 0891-3668/15/3405-0547 DOI: 10.1097/INF.0000000000000607

TABLE 1.  Reported Cases of Epidemic (E) and Sporadic (S) K. kingae Infections Secondary to Hand, Foot and Mouth Disease in Toddlers