[Kingella kingae osteoarticular infections in children. A report of a series of eight new cases]

Kingella kingae is a Gram-negative bacillus which belongs to the Neisseriaceae family. Its involvement in osteoarticular infections is relatively recent.

METHODS AND RESULTS

We report eight cases of Kingella kingae osteoarticular infections that have been diagnosed at the paediatric surgical centre of Rouen University Hospital since October 1995. Six boys and two girls (mean age: 30.6 months) presented with osteomyelitis in six cases and arthritis in two. Only 75% of patients had a fever at time of diagnosis. The biological findings were slightly modified. All samples were obtained from blood, bone or joint fluid. These samples were systematically inoculated into a blood culture tube. Positive Kingella kingae culture was achieved in seven local samples and in one blood culture. All children received two antibiotics via intravenous injection while waiting for the bacteriologic results. Later, the antibiotic treatment (amoxycillin) was given per os. The mean duration of treatment was 33 days. Patients were given intravenous treatment for a period of only ten days. Six patients were followed up for a period of more than 18 months and outcome was always uneventful.

DISCUSSION

Kingella kingae is usually present in the nasopharyngeal mucosa and spreads in the blood due to various infections. Different types of Kingella kingae infection have been reported with a large frequency of osteoarticular infection.

CONCLUSION

This type of infection does not present any unusual characteristics as compared to other osteoarticular infections. Because of its antibiotic sensitivity treatment duration could be reduced. Kingella kingae is a fragile microbe and its culture is often difficult; therefore, it is important to use blood culture tubes to inoculate joint fluid and bone samples.

The prevalence of potentially pathogenic bacteria in nasopharyngeal samples from individuals with a long-standing cough-clinical value of a nasopharyngeal sample

BACKGROUND

A long-standing cough is a common cause for visits to a GP. If the patient also has a respiratory tract infection, one of the concerns of the doctor is to decide if the cough is caused by an underlying bacterial infection.

OBJECTIVES

Our aim was to investigate whether a nasopharyngeal sample, obtained in routine medical practice, could yield information about the aetiology of a long-standing cough in patients with a respiratory tract infection.

METHODS

The prevalence of potentially pathogenic bacteria (Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis) in nasopharyngeal swab samples from 618 healthy individuals was compared with that from 236 patients with a respiratory tract infection and long-standing cough (>9 days) of the same age in a defined geographical area.

RESULTS

The proportion of cultures with potentially pathogenic bacteria decreased with age and was 44% among healthy individuals of pre-school age, 13% in schoolchildren and 6% in adults. The corresponding figures for patients with a long-standing cough were 83, 35 and 36%, respectively. All types of potentially pathogenic bacteria were found more frequently in pre-school children and in adults with a long-standing cough compared with healthy individuals of the same age.

CONCLUSIONS

In patients with a respiratory tract infection and a long-standing cough, where a bacterial infection is suspected on clinical grounds, a nasopharyngeal culture could yield information about the aetiology. If M.catarrhalis is found in pre-school children, or if H.influenzae is found in adults, they are likely to be the aetiological agent.

[Symptoms and clinical and radiological signs predicting the bacterial origin of acute rhinosinusitis]

A minority of patients with common cold and upper respiratory tract infections have a bacterial infection and may benefit from antibiotic therapy. The present analysis set out to determine whether there were clinical symptoms or signs which could help the clinician to identify a subset of patients with moderate forms of acute rhinosinusitis who are infected with pathogenic bacteria. Detailed clinical history and medical examination were obtained from 265 patients (mean age 35 years, 138 females and 127 males) presenting symptoms of upper respiratory tract infections but no fever above 38 degrees C. The presence of three pathogenic bacteria (S. pneumoniae, H. influenzae or M. catarrhalis) was determined in all patients by culture of nasopharyngeal secretions. Aggravating factors for severity of rhinosinusitis, such as severe nasal obstruction, inferior and/or middle turbinate hypertrophy, oedema of the middle meatus mucosa and septal defects, were not associated with the presence of bacteria. Pathogenic bacteria were found in 77 patients (29%). The clinical signs and symptoms which were significantly associated in a multivariate model with the presence of bacteria included facial pain (p < 0.003), coloured nasal discharge (p < 0.003) and radiological maxillary sinusitis (complete opacity, air-fluid level or mucosal thickening greater than 10 mm) (p < 0.002). This, the best predictive model, had a sensitivity of 69% and a specificity of 64% and therefore could not be used either as a screening tool or as a diagnostic criterion for bacterial rhinosinusitis. We conclude that signs and symptoms of acute rhinosinusitis in patients with a mild to moderate clinical presentation are poor predictors of the presence of bacteria. In agreement with previous studies, culture of nasopharyngeal secretions may identify patients who would benefit from antibiotic treatment. Thus, antibiotic therapy should not be prescribed in the absence of bacteriological evidence.

[Haptoglobin in cerebrospinal fluid as a marker of infectious process in central nervous system]

INTRODUCTION

Haptoglobin is a transport protein and protects organism against iron loss and it should be involved in central nervous system infectious process.

PATIENTS AND METHODS

Simultaneous serum and cerebrospinal fluid were obtained of 39 pediatric patients, 14 suffering from viral meningoencephalitis and 25 from bacterial meningoencephalitis. Five control cases were examined too. Haptoglobin, IgG and albumin were quantified in both fluids by radial immunodiffusion. Haptoglobin cerebrospinal fluid/serum ratio, haptoglobin index and haptoglobin/IgG index were calculated. Local IgG intrathecal synthesis was determined by reibergram.

RESULTS

Haptoglobin index was higher not statistically significant in viral meningoencephalitis in comparison with bacterial disease but both were statistically significant with respect to control group. Increased haptoglobin/IgG index were statistically significant in bacterial meningoencephalitis in relation with viral meningoencephalitis. There were no association between haptoglobin and polymorphonuclear cells count and globular sediment speed.

CONCLUSION

Haptoglobin should be considered a relevant marker of central nervous system infectious process.

Glucocorticoids in central nervous system bacterial infection

OBJECTIVE

To evaluate evidence-based data on adjunctive glucocorticoid therapy in central nervous system bacterial infections.

DESIGN

A literature review of studies, particularly controlled trials, that have evaluated dexamethasone therapy for acute bacterial meningitis and glucocorticoid therapy for tuberculous meningitis.

MAIN OUTCOME MEASURES

Clinical outcomes were mortality and morbidity rates. Morbidity involved sensorineural hearing loss and other neurologic deficits (motor or behavioral disturbances, epilepsy, cranial nerve palsy, hydrocephalus, and psychomotor retardation).

RESULTS

The evidence-based data support adjunctive dexamethasone therapy for children with Haemophilus influenzae meningitis. However, the optimal duration of therapy is not defined. Data are supportive but not conclusive that dexamethasone benefits meningitis caused by other bacterial agents and meningitis in adults. The evidence-based data are supportive but not conclusive that adjunctive glucocorticoid therapy benefits patients with tuberculous meningitis, particularly those with more severe infection.

CONCLUSIONS

Although adjunctive glucocorticoid therapy may be beneficial in both acute bacterial meningitis and more severe tuberculous meningitis, there are conclusive data only for H influenzae meningitis in children. For acute bacterial meningitis, further studies are needed to clarify the optimal duration of dexamethasone therapy (2 vs 4 days), whether this therapy should be used routinely for adults with meningitis, and whether it should be used for pathogens other than H influenzae. For tuberculous meningitis, further studies are needed to provide conclusive evidence of benefit.

Moraxella catarrhalis endocarditis: report of a case and literature review

A 53-year-old man developed severe acute systemic illness three weeks after an upper respiratory tract infection. Serial blood cultures grew Moraxella catarrhalis. During antibiotic treatment, fever and infectious parameters disappeared, but severe aortic regurgitation developed. Aortic valve replacement was performed, during which extensive destruction of the aortic valve was noted. Endocarditis due to M. catarrhalis is very rare with, to our knowledge, only six cases having been reported to date. M. catarrhalis is a normal commensal of the upper respiratory tract, but in unpredictable circumstances can become an important pathogen. Bacteremia due to this organism therefore requires prompt treatment, as serious organ complications, including endocarditis, can occur.

[Multifocal invasive Kingella kingae infection]

CASE REPORT

A 2-year-old child, non immunodeficient, presented with septicemia due to Kingella kingae successively complicated by meningitis, arthritis of one knee and endocarditis. Outcome was favourable after a long and adjusted antibiotherapy, involving in particular for the endocarditis ceftriaxone (100 mg/kg/d) and amikacin (20 mg/kg/d) during 3 weeks, then amoxicillin per os (200 mg/kg/d) during 3 weeks.

CONCLUSIONS

Bacteriologic characteristics of the bacteria, the culture of which requires medium base with additional nutrient are reviewed. The tropism of Kingella kingae is essentially osteoarticular and cardiac as shown by the cases reported in the literature. Its susceptibility to antibiotics explains the frequent favourable outcome.

Lumbar facet joint infection associated with epidural and paraspinal abscess

A case of lumbar facet joint infection associated with abscesses of the paraspinal muscles and the epidural space is presented. The infection did not respond to intravenous antibiotic therapy and resolved only after incision and drainage of the epidural space, involved facet joint, and paraspinal musculature. Magnetic resonance imaging, which showed a widened facet joint, epidural abscess, and paraspinal involvement, aided in diagnosis and preoperative planning. This condition is rare, and this report outlines some clinical characteristics of the infection and the usefulness of magnetic resonance imaging in visualizing the extent of the infection.

[A case of acute mediastinitis with pyothorax secondary to peritonsillar abscess]

A 41-year-old man was admitted to a hospital elsewhere because of tonsillitis with high grade fever. On the 9th day of hospitalization, the patient complained of dysphagia and dyspnea. A chest X-ray film and a CT scan showed right pleural effusion and pericardial effusion, and he was referred to our hospital. Immediately after admission, he underwent pericardiotomy to relieve cardiac tamponade, and a right thoracic tube was inserted for pyothorax. Next day, mediastinal drainage was accomplished through a cervical incision and a right thoracotomy. Eight drainage tubes were left in place. Cultures revealed alpha-Streptococcus, Neisseria and group F Streptococci. Continuous closed irrigation with diluted Isodine (povidone iodine) solution was performed. The last extubation of the drainage tube was done on the 140th day after operation. He was cured and discharged on the 162nd day after operation. In patients with extensive acute mediastinitis secondary to deep cervical infection, early complete mediastinal drainage via a cervical and a transthoracic incision is essential.

[Neisseria Sicca endocarditis disclosed by multiple organ failure syndrome]

The authors report a case of Neisseria sicca endocarditis presenting with multiple organ failure in a 33 year old intravenous drug user. The diagnosis was confirmed by transthoracic and transoesophageal echocardiography showing vegetations on the aortic valve and three blood cultures positive for Neisseria Sicca. Massive aortic regurgitation occurred on the 4th day. The patient died of complications of intracerebral haematomas before surgical intervention. Contrary to pathogenic Neisseria gonorrhoeae and meningitides, saprophytic Neisseria, including Neisseria sicca, are commensal organisms of the upper respiratory tract. They are exceptionally rare causes of endocarditis. A review of the literature from the era of antibiotic therapy, found about thirty cases of saprophytic Neisseria endocarditis of which only five were due to Neisseria sicca. The clinical characteristics were the young age, the mainly left heart valve disease and the high incidence of cerebrovascular accidents. The originality of this case was the exceptionally rare involvement of this organism and the multiplicity of the extracardiac manifestations, especially renal and neurological.

Spectrum and significance of bacteremia due to Moraxella catarrhalis

Fifty-eight cases of bacteremia due to Moraxella catarrhalis, including seven that occurred in patients treated at our facilities, are analyzed. The host's medical history plays a major role in the presentation and outcome of M. catarrhalis bacteremia. Bacteremia is typically accompanied by pneumonia in adults with underlying respiratory disease. Many neutropenic patients do not manifest a focus of infection; in contrast, the source identified in healthy, immunocompetent patients is usually the upper airway or the ears. In the recent literature, it has been reported that a rash is typically absent in adults with bacteremic pneumonia and in immunocompetent hosts and that only some neutropenic patients have a rash. The prognosis is grave for patients with endocarditis and for patients with immunoglobulin deficiency or neutropenia not related to a hematologic malignancy. In addition, mortality is substantial among bacteremic patients with respiratory conditions or other chronic debilities, especially when respiratory copathogens are present. The prognosis is good for febrile neutropenic patients with underlying leukemia or lymphoma when the neutropenia resolves. When healthy, immunocompetent individuals are affected with M. catarrhalis bacteremia, their presentations range from self-limited febrile illness to life-threatening disease.

The protective efficacy of cloned Moraxella bovis pili in monovalent and multivalent vaccine formulations against experimentally induced infectious bovine keratoconjunctivitis (IBK)

Calves were vaccinated with cloned Moraxella bovis pili of serogroup C (experiment 1) or B (experiment 2) either as a monovalent formulation or as part of a multivalent preparation with pili of six other serogroups. Within 4 weeks of the second vaccine dose vaccinated calves and non-vaccinated controls were challenged via the ocular route with either virulent M. bovis strain Dal2d (serogroup C) or M. bovis strain 3WO7 (serogroup B) in experiments 1 and 2, respectively. Calves vaccinated with multivalent vaccines had significantly lower antibody titres than those vaccinated with monovalent preparations. Nevertheless, the levels of protection against infectious bovine keratoconjunctivitis (IBK) achieved with multivalent vaccines were 72% and 83% for the groups challenged with M. bovis strains of serogroups B and C, respectively. The serogroup C monovalent vaccine gave 100% protection against experimentally induced IBK and M. bovis isolates cultured from the eyes 6 days post-challenge were identified as belonging solely to serogroup C. Unexpectedly, only 25% protection was achieved against homologous strain challenge of calves that received the monovalent serogroup B vaccine. Furthermore, the majority of M. bovis isolates recovered from calves in this group belonged to serogroup C, as did half of those isolates cultured from the multivalent vaccinates. The remaining bacterial isolates from the latter group, together with all isolates from the non-vaccinated controls, belonged to serogroup B. Results are consistent with the hypothesis that derivatives of the serogroup B challenge inoculum had expressed serogroup C pilus antigen within 6 days of the challenge, possibly as a result of pilus gene inversion occurring in response to the presence of specific antibody in eye tissues and tears.

Experimental evidence for Moraxella-induced penicillin neutralization in pneumococcal pneumonia

Resistance of microorganisms to antimicrobial agents is an increasing problem in the treatment of infectious diseases. In mixed infections, an interesting development can arise when one organism protects another from being killed by an antibiotic. Unfortunately, in the case of respiratory tract infections, experimental evidence of this development is poor. In this study, mice intranasally infected with a lethal number of pneumococci and treated with a curative dose of penicillin or amoxicillin died from pneumococcal pneumonia when they were coinoculated with beta-lactamase-producing Moraxella catarrhalis. beta-lactamase-negative M. catarrhalis did not show a similar indirect pathogenic effect. Treatment with a combination of amoxicillin and the beta-lactamase inhibitor clavulanic acid was not affected by beta-lactamase-producing M. catarrhalis. These findings help explain antibiotic failure in respiratory tract infections, even though the causative microorganism is sensitive to the antibiotic in vitro.

[Neisseria mucosa endocarditis complicated by intracerebral aneurysm]

BACKGROUND

Serious complications, such as emboli and mycotic aneurysms, are still frequent in documented cases of infective endocarditis. Infecting organisms other than Streptococcus viridans and Staphylococcus are becoming more common.

CASE REPORT

A 8 year-old girl was admitted because of a sudden pain in the right calf followed by complete disability. She had low-grade fever and presented with a moderate heart murmur with no sign of congestive heart failure, a severe pain at palpation of her calf with no Homans sign; she had many dental caries. Laboratory data indicated leukocytosis with increased percentage of polymorphonuclear cells and increased sedimentation rate. Ultrasonography of the calf showed laceration of the muscle with blood suffusion. Echocardiography showed vegetations involving the mitral valve. Intravenous antibiotic therapy with penicillin G and netilmicin was instituted, but mitral insufficiency appeared 7 days later while the fever persisted. At that time, the brain CT scan showed ischemic lesions, while angiography showed several mycotic aneurysms. Neisseria mucosa was recovered from the 5 initial blood cultures 16 days after the onset, and penicillin G was replaced by ampicillin. A second vegetation involving the aortic valve was seen a few days later, and a recent arterial embolism to the right leg was suspected because fever and pain reappeared. The brain ischemic lesions gradually disappeared and a second angiography performed 3 months after the first showed that all but one large mycotic aneurysm had disappeared; this last aneurysm was excised. Four years later, the child is in good health without any neurological sequelae but having mitral insufficiency.

CONCLUSION

This girl presented with classical complication of infective endocarditis due to Neisseria mucosa, a saprophytic organism of the oral cavity. This is the second report of such an infection in children.