Original Article

Kingella kingae endophthalmitis in an infant S, M. Carden, MB BS" D. J. Colville, MB BS, FRACO, FRACSY G. Gonis, BSc (Hans)$ G. L. Gilbert, MB BS, FRACP, FRCPAg

Abstract An 11-month-old girl presented with metastatic endophthalmitis. The causative organism was the Gram-negative coccobacillus Kingella kingae. This is an uncommon organism first recognised in 1967. It has never been previously reported to cause endophthalmitis, but is associated with at least four other infective syndromes in children. Endophthalmitis is a potentially lethal and sightthreatening disease. Kingella kingae is primarily a paediatric pathogen which fortunately responds well to antibiotics. A case study, details of the bacteriology and a table of other clinical syndromes associatedwith this organism seen at our institution constitute this article. (12 references)

slowly in culture, its natural habitat has not been precisely defined and the clinical manifestations of infection are non-specific and can be subacute2(See Table 1).

Endophthalmitis is most commonly related to surgical or accidental trauma, but metastatic (or endogenous) endophthalmitis is also well recognised.' The clinical importance of Kingella kingue has only recently been recognised because it grows

Case Report Presentation A previously well 1 1-month-old girl was admitted to the Royal Children's Hospital in November 1989. Her parents had noticed that her right eye had been red and the lids puffy for 12 hours; there was some epiphora but no purulent discharge. She had been seen by her general practitioner, referred the same day to an ophthalmologist and admitted for investigation of unilateral hypopyon. She was a first-born twin and had no facial trauma, recent recognised upper respiratory infection or allergies. Examination on admission showed that the infant was febrile with a temperature of 38.1 "C. There was no strabismus or motility disorder. Her right conjunctiva was injected, the cornea was macroscopically clear but a small hypopyon was present. General examination showed an inflamed pharynx but no other abnormality. In particular, there was no cardiac murmur, meningism or joint swelling. Her weight was 11.2 kg (greater than the 90th percentile) and head circumference 45.2 cm (45th percentile).

*Ophthalmic Resident Medical Officer ?Ophthalmic Surgeon $Hospital Scientist, Department of Microbiology/Infectious Disease §Director, Department of Microbiology/Infectious Disease From Royal Children's Hospital, Parkville, Victoria.

Initial examination and eye findings on examination under anaesthesia (E UA) A vitreoretinal surgeon was consulted in view of the belief that early vitrectomy in endophthalmitis

Key words: Antibiotic therapy, bacterial taxonomy, endogenous endophthalmitis, host immunity, hypopyon, indolent course, infant, Kingella kingae, metastatic endophthalmitis.

Reprint requesrs: Dr Deborah Colville, Ophthalmic Surgeon, Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052, Australia. KingeNa kingae endophthalmitis in an infant

217

Fig. 1_Horse-blood agar (HBA) plate after three days of aerobic culture shows haemolysis and two colony types Kingella kingae.

Fig. 2. - HBA plate after five days of anaerobic culture shows pitted colony Kingella kingae.

can influence o ~ t c o m e .T~h e infant was then examined under anaesthesia on the night of admission. A diagnostic paracentesis was performed on the right eye; the hypopyon consisted of gelatinous, cream-coloured material both inferiorly and superiorly, and covering the iris. On gonioscopy no foreign body was detected in association with the superior collection. T h e iris vessels looked dilated and there was ciliary injection. Slit lamp examination showed no corneal abrasion after fluorescein staining. T h e vitreous view was obscured by haze, but the fundus was considered normal. T h e other eye was entirely normal. T h e differential diagnosis was endophthalmitis, uveitis or retinoblastoma. In view of the mild subacute symptoms, diagnostic vitreous biopsy and

intravitreal antibiotic therapy were deferred in favour of a trial of intravenous antibiotic therapy. T h e next morning she was no worse.

Table 1. Kingella infections at the Royal Children's Hospital, Melbourne Case Number

Year

Age of Patient

Sex

1

1978

6 months

Male

2

1979 1985 1988 1989 1989 1989 1989 1989 1990

2 years

Male Male Female Female Female Male Female Female Male

3 4

5 6 7 8 9 10

218

10 years 1 year

12 years 6 months 9 months 1 1 months 1 1 months

18 months

Site of infection Osteomyelitis sternum Osteomyelitis femur Endocarditis Endocarditis Discitis Bacteraemia Septicaemia Osteomyelitis tibia Endophthalmitis Endocarditis

Microbiological findings Gram stain of the aqueous fluid showed a moderate number of polymorphs and rare Gram-negative coccobacilli. Haemophilus influenzae type b was considered the most likely organism, but the isolate was identified as Kingella kingae on the basis of typical colonial morphology, beta-haemolysis and biochemical reactions as described below. Clinical course During the first week the infant underwent three E U A s . After subconjunctival a n d topical antibiotics, atropine and later topical corticosteroids were given, her condition improved and by day five there was no frank hypopyon. Vitreous biopsy and intravitreal antibiotics were not required. Anterior vitreous cells became visible as her anterior chamber cleared and no fundal pathology was observed. It seemed likely that the vitreous cells had been present from presentation. Laboratory results T h e only positive findings were: isolation of rhinovirus from the nasopharyngeal aspirate, ESR 19 mmlh and a mildly elevated white cell count (18.5 x 109/L)with a mild neutrophilia (43%) and 4% band forms. T h e remaining investigations were unremarkable. Endocarditis was excluded by Australian and New Zealand Journal of Ophthalmology 1991; 19(3)

influenzae type b in infants, and Neisseria meningitidis.’ We can find no previous report of KingeIIa kingae causing endophthalmitis. Most reported infections of KingeIla kingae have been in children in whom it causes bone and joint infections, endocarditis and septicaemia.2.8The first case of KingeIIa kingae infection recognised at Royal Children’s Hospital, Melbourne, was in 1978 and there have been a total of 10cases to date (seeTable 1).

Fig. 3. -Diagram of presenting anterior segment findings of hypopyon Kingella kingae endophthalmitis.

negative blood cultures and a structurally normal heart with no vegetations on echocardiography. Electrolytes, renal and liver function tests, Creactive protein, CSF examination, orbital X-ray and chest X-ray also revealed no abnormality. Haemophilus influenzae type b antigen was not detected in urine by latex agglutiiation, and enzyme-linked immunoassays for serum IgG antibodies against toxoplasma and toxocara were negative.

Treatment and follow-up The treatment consisted of chloramphenicol drops initially. She was then given cefotaxime at doses sufficient for meningitis treatment, 200 mglkg per day intravenously. The topical regimen chosen was cefotaxime drops 50 mglmL hourly and atropine 1% drops twice daily. After 48 hours she was commenced on prednisolone 1Yolphenylephrine 0.12% drops every two hours. During the first week three subconjunctival injections of gentamicin (20 mg) and dexamethasone (2 mg) were given. After seven days of intravenous antibiotic therapy, treatment was changed to oral chloramphenicol (80 mglkglday). She was discharged from hospital on day 12 on oral and topical chloramphenicol, with continued prednisolone drops. All medication was ceased on day 25. The patient’s eye was normal at follow-up more than two months later. She had no strabismus and her fixation was central and steady.

Discussion Bacterial infection in the anterior chamber in a child of this age in the absence of trauma or systemic disease is very rare. Reports suggest that 90% of all cases of endophthalmitis are exogenous and 7% to 15% m e t a ~ t a t i c . The ~ - ~ more common causes of endogenous bacterial endophthalmitis in children are group B streptococcus in neonates, Haemophilus Kingella kingae endophthalmitis in an infant

Bacteriology The taxonomy of KingeIIa kingae is of interest. It belongs to the family Neisseriaceae, which includes the genera Neisseria, Branhamella, Moraxella, Actinobacter and Kingella. Kingella kingae is a fastidious Gram-negative coccobacillus. It was initially placed in the genus Moraxella and incorrectly named M. kingii after Dr Elizabeth King, who first described it. Its present name Kingella kingae recognises its generic difference from other similar organisms and the gender of the person for whom it was It is differentiated from similar organisms by its typical colonial morphology (two different types of which one pits the agar), beta haemolysis and biochemical reactions: it is nonmotile, oxidase positive, and catalase, indole and nitrate reductase negative, and produces acid from glucose and maltose. Kingella kingue is aerobic but pitted colonies grow better anaerobically. It is highly susceptible to most commonly used antibiotics including penicillin and other betalactams, chloramphenicol and a m i n ~ g l y c o s i d e s , ~ ~ ~ ~ ~ ~ but resistant to clindamycin.2 Host susceptibility is relevant to this case. The upper respiratory tract is the probable source of systemic infection with KingeIIa kingae, which is often preceded by upper respiratory infection.’* Rhinovirus from nasopharyngeal aspirate was isolated in our patient, which may have caused a breach of membrane defence. The carriage rate of Kingella kingae is unknown and it is difficult to isolate from normal respiratory flora. Transient bacteraemias are presumably caused by local mucosal damage and occasionally complicated by metastatic focal disease. T h e frequency of coincidental viral respiratory (e.g. rhinovirus) infection, with or without respiratory symptoms, in patients with proven KingeIIa kingae infection would be interesting. Acknowledgements Thanks are due to Dr Jim Goutzamanis, Fellow in Infectious Diseases, Royal Children’s Hospital, Dr 219

Keith Grimwood, Paediatrician, Royal Children's Hospital, Ms Kerrie Stevens, Hospital Scientist, Department of Microbiologyhfectious Disease, Royal Children's Hospital and Dr Tom Chia, the ophthalmologist who referred the case to us.

References 1. Moore A. Endophthalmitis. In: Taylor D, ed. Pediatric Ophthalmology. Boston: Blackwell Scientific Publications 1990;114-118. 2. Bosworth DE. Kingella (Moraxella) kingae infections in children. Am J Dis Chid 1983;137:650-653. 3. Shrader SK, Band JD, Lauter CB, Murphy P. The clinical spectrum of endophthalmitis:Incidence, predisposing factors and features influencing outcome. J Infec Dis 1990; 162:115-120. 4. Forster RK, Abbott RL, Gelender H. Management of infectious endophthalmitis. Ophthalmology 1980;87:313-319. 5. Rowsey JJ, Newsom DL, Sexton DJ, Harms WK. Endophthalmitis. Current approaches. Ophthalmology 1982;89: 1055-1066.

6. Verbraeken H. Sur l'etiologie des endophthalmies. J Fr Ophthalmol 1986;9(5):381-383. 7. Greenwald MJ, Wohl LG, Sell CS. Metastatic bacterial endophthalmitis: a contemporary appraisal. Surv Ophthal 1986;31(2):81-101. 8. De Groote 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;10(5): 998-1004. 9. Henriksen SD, Bovre K. Transfer of Moraxella Kingae Henriksen and Bovre to the Genus Kingella gen. nov. in the Family Neisseriaceae. Inr J Sys Bacteriol 1976;26(4):447-450. 10. Bovre K, Henriksen SD, Jonsson V. Correction of the specific epithet Kingii in Combinations, Moraxella Kingii, Henriksen and Bovre, 1968 and Pseudomonas Kingii, Jonsson 1970 to Kingae 1974. Int J Sys Bacteriol 1974; 24:307. 11. Forstl H. Septicaemia caused by Kingella Kingae. Eur J Clin Microbiol 1984;3:267-269. 12. Henriksen SD. Corroding bacteria from the respiratory tract 1 Moraxella kingii. Acta Path Microbiol Scandinav 1969; 75~85-90.

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Australian and New Zealand Journal of Ophthalmology 1991; (19)3