Kingella kingae Sequence Type 25 Causing Endocarditis with Multiple and Severe Cerebral Complications
A
14-month-old-girl was diagnosed with influenza A encephalomyelitis based on fever, prostration, hypertonia, hyperalgesia, urinary retention, positive influenza A real-time polymerase chain reaction on nasopharyngeal sample, and meningitis. Cerebral and medullary magnetic resonance imaging showed multiple white matter lesions with T2-weighted hypersignal and apparent diffusion coefficient restriction (Figure, A-C). Thus, she was treated with 5 methylprednisolone bolus. After the last bolus, a systolic cardiac murmur was heard. Transthoracic echocardiography showed vegetation and a perforation on mitral valve. Concomitantly, initial blood culture revealed a sequence type 25 Kingella kingae strain,1 and specific polymerase
Figure. Brain MRI at day 3 shows lesions of the right centrum semiovale (1) and the distal posterior sylvian vascular territory (2) with apparent diffusion coefficient restriction on A, diffusion-weighted imaging and B, T2-weighted imaging. Spinal MRI shows diffuse intraspinal T2-weighted hypersignal at C, day 3 and D, return to normal at day 13. E, T1-weighted sequence with gadolinium, on cerebral MRI at day 13 shows a posterior insular infracentimetric lesion enhancement consistent with cerebritis (3) and a small cortical vascular dilatation in the left occipital lobe (4). F, Computed tomography 3 weeks after admission shows left parieto-occipital hemorrhagic stroke (5) with intra-ventricular hemorrhage (6) and sub-falcine herniation (7). MRI, magnetic resonance imaging.
J Pediatr 2016;169:326. 0022-3476/$ - see front matter. Copyright ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2015.10.091
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chain reaction2 was positive in the cerebrospinal fluid. She received amoxicillin and ciprofloxacin treatment. Three days later, magnetic resonance imaging showed insular lesion consistent with cerebritis and small cortical vascular dilatation in the left cuneus; medullar images were back to normal (Figure, D and E). Three weeks after admission, she worsened because of mycotic aneurysm rupture leading to left parieto-occipital hemorrhagic stroke, intra-ventricular hemorrhage, and sub-falcorial herniation (Figure, F), which were neurosurgically treated. Eight weeks after admission, she improved with mild right hemiparesis and hemianopsia persistence, and the mitral regurgitation will need surgical repair. K kingae endocarditis is a rare but severe infection, with frequent neurologic complications, occurring mostly on a native valve in healthy children.3 Bacteriologic diagnosis is a challenge because K kingae has been exceptionally isolated in the blood and in the cerebrospinal fluid. Although respiratory viruses are probably involved in the pathophysiology of K kingae infections,4 this case presented with influenza A coinfection. Given that influenza A may be associated with severe bacterial infections,5 involvement of this co-infection in the severity of our case remains to be determined. n
F leur Le Bourgeois, MD David Germanaud, MD, PhD Matthieu Bendavid, MD Ronan Bonnefoy, MD Beatrice Desnous, MD Constance Beyler, MD Thomas Blauwblomme, MD Monique Elmaleh, MD Charlotte Pierron, MD Mathie Lorrot, MD, PhD Stephane Bonacorsi, MD, PhD Romain Basmaci, MD, PhD
Detailed affiliations available at www.jpeds.com References available at www.jpeds.com
Volume 169 February 2016
AP-HP, Service de Reanimation Pediatrique
Univ Paris Diderot, Sorbonne Paris Cite URMS 1123 ECEVE
David Germanaud, MD, PhD
Stephane Bonacorsi, MD, PhD
AP-HP, Service de Neurologie Pediatrique H^ opital Robert-Debre, Paris CEA, NeuroSpin, UNIACT, Gif-sur-Yvette
AP-HP, Laboratoire de Microbiologie
Fleur Le Bourgeois, MD
Matthieu Bendavid, MD AP-HP, Service de Pediatrie Generale
Ronan Bonnefoy, MD AP-HP, Service de Cardiologie Pediatrique
Romain Basmaci, MD, PhD AP-HP, Service de Pediatrie Generale AP-HP, Laboratoire de Microbiologie H^ opital Robert-Debre, Paris INSERM, IAME, UMR 1137 Univ Paris Diderot, Sorbonne Paris Cite Paris, France
Beatrice Desnous, MD AP-HP, Service de Neurologie Pediatrique
Constance Beyler, MD AP-HP, Service de Cardiologie Pediatrique H^ opital Robert-Debre, Paris
Thomas Blauwblomme, MD AP-HP, Service de Neurochirurgie H^ opital Necker Enfants Malades, Paris Universite Rene Descartes PRES Sorbonne Paris Cite
Monique Elmaleh, MD AP-HP, Service de Radiologie Pediatrique
Charlotte Pierron, MD AP-HP, Service de Reanimation Pediatrique
Mathie Lorrot, MD, PhD AP-HP, Service de Pediatrie Generale H^ opital Robert-Debre, Paris
References 1. Basmaci R, Bidet P, Yagupsky P, Munoz-Almagro C, Balashova NV, Doit C, et al. Major intercontinentally distributed sequence types of Kingella kingae and development of a rapid molecular typing tool. J Clin Microbiol 2014;52:3890-7. 2. Ilharreborde B, Bidet P, Lorrot M, Even J, Mariani-Kurkdjian P, Liguori S, et al. New real-time PCR-based method for Kingella kingae DNA detection: application to samples collected from 89 children with acute arthritis. J Clin Microbiol 2009;47:1837-41. 3. Foster MA, Walls T. High rates of complications following Kingella kingae infective endocarditis in children: a case series and review of the literature. Pediatr Infect Dis J 2014;33:785-6. 4. Basmaci R, Bonacorsi S, Ilharreborde B, Doit C, Lorrot M, Kahil M, et al. High respiratory virus oropharyngeal carriage rate during Kingella kingae osteoarticular infections in children. Future Microbiol 2015;10:9-14. 5. Niemann S, Ehrhardt C, Medina E, Warnking K, Tuchscherr L, Heitmann V, et al. Combined action of influenza virus and Staphylococcus aureus panton-valentine leukocidin provokes severe lung epithelium damage. J Infect Dis 2012;206:1138-48.
326.e1
A
14-month-old-girl was diagnosed with influenza A encephalomyelitis based on fever, prostration, hypertonia, hyperalgesia, urinary retention, positive influenza A real-time polymerase chain reaction on nasopharyngeal sample, and meningitis. Cerebral and medullary magnetic resonance imaging showed multiple white matter lesions with T2-weighted hypersignal and apparent diffusion coefficient restriction (Figure, A-C). Thus, she was treated with 5 methylprednisolone bolus. After the last bolus, a systolic cardiac murmur was heard. Transthoracic echocardiography showed vegetation and a perforation on mitral valve. Concomitantly, initial blood culture revealed a sequence type 25 Kingella kingae strain,1 and specific polymerase
Figure. Brain MRI at day 3 shows lesions of the right centrum semiovale (1) and the distal posterior sylvian vascular territory (2) with apparent diffusion coefficient restriction on A, diffusion-weighted imaging and B, T2-weighted imaging. Spinal MRI shows diffuse intraspinal T2-weighted hypersignal at C, day 3 and D, return to normal at day 13. E, T1-weighted sequence with gadolinium, on cerebral MRI at day 13 shows a posterior insular infracentimetric lesion enhancement consistent with cerebritis (3) and a small cortical vascular dilatation in the left occipital lobe (4). F, Computed tomography 3 weeks after admission shows left parieto-occipital hemorrhagic stroke (5) with intra-ventricular hemorrhage (6) and sub-falcine herniation (7). MRI, magnetic resonance imaging.
J Pediatr 2016;169:326. 0022-3476/$ - see front matter. Copyright ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2015.10.091
326
chain reaction2 was positive in the cerebrospinal fluid. She received amoxicillin and ciprofloxacin treatment. Three days later, magnetic resonance imaging showed insular lesion consistent with cerebritis and small cortical vascular dilatation in the left cuneus; medullar images were back to normal (Figure, D and E). Three weeks after admission, she worsened because of mycotic aneurysm rupture leading to left parieto-occipital hemorrhagic stroke, intra-ventricular hemorrhage, and sub-falcorial herniation (Figure, F), which were neurosurgically treated. Eight weeks after admission, she improved with mild right hemiparesis and hemianopsia persistence, and the mitral regurgitation will need surgical repair. K kingae endocarditis is a rare but severe infection, with frequent neurologic complications, occurring mostly on a native valve in healthy children.3 Bacteriologic diagnosis is a challenge because K kingae has been exceptionally isolated in the blood and in the cerebrospinal fluid. Although respiratory viruses are probably involved in the pathophysiology of K kingae infections,4 this case presented with influenza A coinfection. Given that influenza A may be associated with severe bacterial infections,5 involvement of this co-infection in the severity of our case remains to be determined. n
F leur Le Bourgeois, MD David Germanaud, MD, PhD Matthieu Bendavid, MD Ronan Bonnefoy, MD Beatrice Desnous, MD Constance Beyler, MD Thomas Blauwblomme, MD Monique Elmaleh, MD Charlotte Pierron, MD Mathie Lorrot, MD, PhD Stephane Bonacorsi, MD, PhD Romain Basmaci, MD, PhD
Detailed affiliations available at www.jpeds.com References available at www.jpeds.com
Volume 169 February 2016
AP-HP, Service de Reanimation Pediatrique
Univ Paris Diderot, Sorbonne Paris Cite URMS 1123 ECEVE
David Germanaud, MD, PhD
Stephane Bonacorsi, MD, PhD
AP-HP, Service de Neurologie Pediatrique H^ opital Robert-Debre, Paris CEA, NeuroSpin, UNIACT, Gif-sur-Yvette
AP-HP, Laboratoire de Microbiologie
Fleur Le Bourgeois, MD
Matthieu Bendavid, MD AP-HP, Service de Pediatrie Generale
Ronan Bonnefoy, MD AP-HP, Service de Cardiologie Pediatrique
Romain Basmaci, MD, PhD AP-HP, Service de Pediatrie Generale AP-HP, Laboratoire de Microbiologie H^ opital Robert-Debre, Paris INSERM, IAME, UMR 1137 Univ Paris Diderot, Sorbonne Paris Cite Paris, France
Beatrice Desnous, MD AP-HP, Service de Neurologie Pediatrique
Constance Beyler, MD AP-HP, Service de Cardiologie Pediatrique H^ opital Robert-Debre, Paris
Thomas Blauwblomme, MD AP-HP, Service de Neurochirurgie H^ opital Necker Enfants Malades, Paris Universite Rene Descartes PRES Sorbonne Paris Cite
Monique Elmaleh, MD AP-HP, Service de Radiologie Pediatrique
Charlotte Pierron, MD AP-HP, Service de Reanimation Pediatrique
Mathie Lorrot, MD, PhD AP-HP, Service de Pediatrie Generale H^ opital Robert-Debre, Paris
References 1. Basmaci R, Bidet P, Yagupsky P, Munoz-Almagro C, Balashova NV, Doit C, et al. Major intercontinentally distributed sequence types of Kingella kingae and development of a rapid molecular typing tool. J Clin Microbiol 2014;52:3890-7. 2. Ilharreborde B, Bidet P, Lorrot M, Even J, Mariani-Kurkdjian P, Liguori S, et al. New real-time PCR-based method for Kingella kingae DNA detection: application to samples collected from 89 children with acute arthritis. J Clin Microbiol 2009;47:1837-41. 3. Foster MA, Walls T. High rates of complications following Kingella kingae infective endocarditis in children: a case series and review of the literature. Pediatr Infect Dis J 2014;33:785-6. 4. Basmaci R, Bonacorsi S, Ilharreborde B, Doit C, Lorrot M, Kahil M, et al. High respiratory virus oropharyngeal carriage rate during Kingella kingae osteoarticular infections in children. Future Microbiol 2015;10:9-14. 5. Niemann S, Ehrhardt C, Medina E, Warnking K, Tuchscherr L, Heitmann V, et al. Combined action of influenza virus and Staphylococcus aureus panton-valentine leukocidin provokes severe lung epithelium damage. J Infect Dis 2012;206:1138-48.
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