Letters to the Editor
Io2
EBV should be considered as a possibility in any patient presenting with a clinical diagnosis of encephalitis, especially is aged between I5 and 25 years. Although our patient was given acyclovir, the dose (Io m g / k g body wt) was too low to achieve effective therapeutic concentrations against EBV in vitro. In our opinion the dose of acyclovir (700 m g 8-hourly) used by Bhatti et al., 1 would also have been inadequate. In view of this it is difficult to assess the role of acyclovir in m a n a g e m e n t of EBV encephalitis; however, we would agree that treatment with acyclovir should be initiated on clinical suspicion of viral encephalitis. (We thank Dr C. Hardisty for permission to report on his patient and Mr A. Siddons for performing serological tests.)
Public Heath Laboratory, Northern General Hospital, Herries Road, Sheffield, Yorkshire $5 7A U
D. Sanyal* G. Kudesia
Department of General Medicine, Northern General Hospital, Herries Road, Sheffield, U.K.
M. Young
* Address correspondence to: D. Sanyal, P.H.L.S., Northern General Hospital, Sheffield $5 7AU, U.K.
Reference
r. Bhatti N, Larson E, Hickey M , Seal D. Encephalitis due to Epstein-Barr virus. J Infect I99o; 2o : 69-72.
Kingella kingae
d a c t y l i t i s in a n i n f a n t
Accepted for publication 3 July I99o Sir,
Kingella kingae, formerly known as Moraxella kingae, is a Gram-negative coccobacillary, fermentative rod, that has been chiefly associated with bone and joint infections and endocarditis. 1 Dactylitis due to this organism has seldom been reportedfl We describe an infant with bacteraemia and dactylitis due to K. kingae. A previously healthy 6-month-old male infant was admitted through the Accident and E m e r g e n c y D e p a r t m e n t with 2 days' history of a swollen, erythematous but nontender right little finger. T h e m o t h e r could recall no recent febrile illness or trauma. Examination of the hand confirmed the presence of a swollen erythematous finger, the swelling being m o s t obvious in the proximal half of the digit. It was not tender or hot, and there was a full range of m o v e m e n t in all joints of the hand. F u r t h e r physical findings were unremarkable. L a b o r a t o r y data indicated a peripheral W B C of I6 x ~o 9 with 57 % neutrophils and 43 % lymphocytes. T h e E S R was 32 m m / h . Radiographs of the affected finger and the right hand were normal but the bones were not scanned. Blood cultures yielded G r a m - n e g a t i v e coccobacilli, identified as K. kingae (confirmed by the Central Public Health Laboratory, Colindale, London), sensitive to penicillin, ampicillin, cephradine and gentamicin by disc diffusion susceptibility tests. T h e infant was treated with a combination of Iv ampicillin and IV flucloxacillin (I25 mg of each, given four times a day). On receiving the susceptibility and identification
Letters to the Editor
I03
reports on the third day, therapy was changed to oral ampicillin for a further 5 days. A follow-up visit 3 months after discharge showed full recovery, with normal radiographic findings. T h e clinical presentation of this patient was unique because only soft tissues were affected without any restriction of movement or involvement of the bones and joints. T h e r e was no accompanying febrile illness or history of trauma. T h e patient made a complete clinical recovery and the peripheral W B C and E S R returned to normal within days of completing his antibiotic treatment. T h e significance of the isolate is confirmed by the patient's clinical picture, the isolation of the organism from several blood culture bottles and laboratory data indicative of acute inflammation. T h e commonest pathogens in the aetiology of arthritis and osteomyelitis in infants and young children remain Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae and Streptococcus pyogenes. 3'4 It is possible that fastidious G r a m negative micro-organisms such as K. kingae play a larger role in the pathogenesis of arthritis and osteomyelitis than has previously been reported. 5 Kingella kingae has an affinity for skeletal tissues in infants and children, but the reasons for this are currently unknown. T h e prognosis for clinical recovery following treatment with penicillin is excellent.
*Departments of Orthopaedic Surgery and t Medical Microbiology, Altnagelvin Area Hospital, Londonderry B T47 I SB, Northern Ireland, U.K.
P. E. Chiquito* J. Elliott* S. S. Namnyakt$
:~ Author to whom correspondence should be addressed References
i. Gamble JG, Rinsky LA. Kingella kingae infection in healthy children. J Pediatr Orthop 1988; 8: 445-449. 2. de Groot R, Glover D, Clausen C, Smith AL, Wilson CB. Bone and joint infections caused by Kingella kingae: six cases and review of the literature. Rev Infect Dis 1988; IO: 998-1oo4. 3. Welkon CJ, Long SS, Fisher MC, Alburger PD. Pyogenic arthritis in infants and children : a review of 95 cases. Pediatr Infect Dis 1986; 5: 669-676. 4. Syriopoulou VP, Smith AL. Osteomyelitis and septic arthritis. In: Fegin RD, Cherry JD, eds. Pediatric infectious diseases. End ed. Philadelphia: WB Saunders, 1987: 759-779. 5. Verbruggen AM, Hauglustaine D, Schildermans F et al. Infections caused by Kingella kingae: a report of four cases and review. J Infect 1986; 13: 133-142.
C i p r o f l o x a c i n as a n e f f e c t i v e a n t i b a c t e r i a l a g e n t i n s e r r a t i a e n d o c a r d i t i s
Accepted for publication 3 July 199o Sir, Ciprofloxacin is a fluoroquinolone derivative with a high degree of tissue penetration and in vitro activity against Gram-positive and Gram-negative bacteria. 1-3 I n spite of m u c h information provided by recent clinical studies with oral and parenteral administration of the drug, there is little data about its efficacy in the treatment of serious endovascular infections such as endocarditis. 4-8 We wish to report two cases of left-sided infective endocarditis caused by Serratia species and successfully treated with IV and oral administration of ciprofloxacin.
Io2
EBV should be considered as a possibility in any patient presenting with a clinical diagnosis of encephalitis, especially is aged between I5 and 25 years. Although our patient was given acyclovir, the dose (Io m g / k g body wt) was too low to achieve effective therapeutic concentrations against EBV in vitro. In our opinion the dose of acyclovir (700 m g 8-hourly) used by Bhatti et al., 1 would also have been inadequate. In view of this it is difficult to assess the role of acyclovir in m a n a g e m e n t of EBV encephalitis; however, we would agree that treatment with acyclovir should be initiated on clinical suspicion of viral encephalitis. (We thank Dr C. Hardisty for permission to report on his patient and Mr A. Siddons for performing serological tests.)
Public Heath Laboratory, Northern General Hospital, Herries Road, Sheffield, Yorkshire $5 7A U
D. Sanyal* G. Kudesia
Department of General Medicine, Northern General Hospital, Herries Road, Sheffield, U.K.
M. Young
* Address correspondence to: D. Sanyal, P.H.L.S., Northern General Hospital, Sheffield $5 7AU, U.K.
Reference
r. Bhatti N, Larson E, Hickey M , Seal D. Encephalitis due to Epstein-Barr virus. J Infect I99o; 2o : 69-72.
Kingella kingae
d a c t y l i t i s in a n i n f a n t
Accepted for publication 3 July I99o Sir,
Kingella kingae, formerly known as Moraxella kingae, is a Gram-negative coccobacillary, fermentative rod, that has been chiefly associated with bone and joint infections and endocarditis. 1 Dactylitis due to this organism has seldom been reportedfl We describe an infant with bacteraemia and dactylitis due to K. kingae. A previously healthy 6-month-old male infant was admitted through the Accident and E m e r g e n c y D e p a r t m e n t with 2 days' history of a swollen, erythematous but nontender right little finger. T h e m o t h e r could recall no recent febrile illness or trauma. Examination of the hand confirmed the presence of a swollen erythematous finger, the swelling being m o s t obvious in the proximal half of the digit. It was not tender or hot, and there was a full range of m o v e m e n t in all joints of the hand. F u r t h e r physical findings were unremarkable. L a b o r a t o r y data indicated a peripheral W B C of I6 x ~o 9 with 57 % neutrophils and 43 % lymphocytes. T h e E S R was 32 m m / h . Radiographs of the affected finger and the right hand were normal but the bones were not scanned. Blood cultures yielded G r a m - n e g a t i v e coccobacilli, identified as K. kingae (confirmed by the Central Public Health Laboratory, Colindale, London), sensitive to penicillin, ampicillin, cephradine and gentamicin by disc diffusion susceptibility tests. T h e infant was treated with a combination of Iv ampicillin and IV flucloxacillin (I25 mg of each, given four times a day). On receiving the susceptibility and identification
Letters to the Editor
I03
reports on the third day, therapy was changed to oral ampicillin for a further 5 days. A follow-up visit 3 months after discharge showed full recovery, with normal radiographic findings. T h e clinical presentation of this patient was unique because only soft tissues were affected without any restriction of movement or involvement of the bones and joints. T h e r e was no accompanying febrile illness or history of trauma. T h e patient made a complete clinical recovery and the peripheral W B C and E S R returned to normal within days of completing his antibiotic treatment. T h e significance of the isolate is confirmed by the patient's clinical picture, the isolation of the organism from several blood culture bottles and laboratory data indicative of acute inflammation. T h e commonest pathogens in the aetiology of arthritis and osteomyelitis in infants and young children remain Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae and Streptococcus pyogenes. 3'4 It is possible that fastidious G r a m negative micro-organisms such as K. kingae play a larger role in the pathogenesis of arthritis and osteomyelitis than has previously been reported. 5 Kingella kingae has an affinity for skeletal tissues in infants and children, but the reasons for this are currently unknown. T h e prognosis for clinical recovery following treatment with penicillin is excellent.
*Departments of Orthopaedic Surgery and t Medical Microbiology, Altnagelvin Area Hospital, Londonderry B T47 I SB, Northern Ireland, U.K.
P. E. Chiquito* J. Elliott* S. S. Namnyakt$
:~ Author to whom correspondence should be addressed References
i. Gamble JG, Rinsky LA. Kingella kingae infection in healthy children. J Pediatr Orthop 1988; 8: 445-449. 2. de Groot R, Glover D, Clausen C, Smith AL, Wilson CB. Bone and joint infections caused by Kingella kingae: six cases and review of the literature. Rev Infect Dis 1988; IO: 998-1oo4. 3. Welkon CJ, Long SS, Fisher MC, Alburger PD. Pyogenic arthritis in infants and children : a review of 95 cases. Pediatr Infect Dis 1986; 5: 669-676. 4. Syriopoulou VP, Smith AL. Osteomyelitis and septic arthritis. In: Fegin RD, Cherry JD, eds. Pediatric infectious diseases. End ed. Philadelphia: WB Saunders, 1987: 759-779. 5. Verbruggen AM, Hauglustaine D, Schildermans F et al. Infections caused by Kingella kingae: a report of four cases and review. J Infect 1986; 13: 133-142.
C i p r o f l o x a c i n as a n e f f e c t i v e a n t i b a c t e r i a l a g e n t i n s e r r a t i a e n d o c a r d i t i s
Accepted for publication 3 July 199o Sir, Ciprofloxacin is a fluoroquinolone derivative with a high degree of tissue penetration and in vitro activity against Gram-positive and Gram-negative bacteria. 1-3 I n spite of m u c h information provided by recent clinical studies with oral and parenteral administration of the drug, there is little data about its efficacy in the treatment of serious endovascular infections such as endocarditis. 4-8 We wish to report two cases of left-sided infective endocarditis caused by Serratia species and successfully treated with IV and oral administration of ciprofloxacin.
