173
Case report
~~~geZZ~kingae, a rare cause of bacterial meningitis J. Van Erps”. E. Schmedding’, A. Naessens’ and B. Keymeulen”
(Received (Revised.
19 August,
1991)
received 21 October,
(Accepted
21 October.
1991)
1991)
Meningitis (bacterial): Kingella kingae
KC-y itwCls:
Summary
A male adolescent with a history of pharyngitis developed meningitis due to King&h kingur. This is a Gram-negative coccobacillus belonging to the family of Neisseriaceae. It is a rarely reported human pathogen. from which only 2 cases of meningitis have been described up to the present day. Our patient developed ophthalmoplegia. suggestive of basal meningitis. He was treated with penicillin G and recovered completely.
Case report
Introduction
a Gram-negative microorganism belonging to the family of Neisseriaceae, is a rarely reported human pathogen. It is occasionally isolated from the nasopharynx in asymptomatic adults. During the last 10 years. an increasing number of reports concerning this bacterial species have been published, and its possibly septic character has been underlined in various infections, such as arthritis, osteomyelitis. endocarditis and bacteremia. Up to now, only 2 cases of meningitis have been pliblished, one in an infant and the other in an adult with sickle cell anemia. In this article we describe the first case of meningitis in a young and otherwise healthy adolescent. Kirtgdiu
kingm.
Cit~~cs~~oftr~~,~~
Medicine, 101.
Academic
B-1090
477.6428.
lo:
Dr.
.fodnna
Hospital.
Brussels.
Van Erps,
Vrije Universiteit
Belgium.
Tel.:
Department
of internal
Brussel, Laarbeeklaan
32-2-477.41.11;
Fax:
32-2-
A previously healthy 17-year-old Belgian man was referred to our hospital because of increasing frontal headache, neckpain and vomiting for 2 days. Antibiotic therapy, consisting of amoxycillin. had been started the day before admission. A week prior to his admission, he had symptoms which were interpreted as a common cold. Physical examination revealed a moderately ill patient, with photophobia. Body temperature was 37.3”C, blood pressure 130180 mm Hg and pulse rate 4O/min. He had nuchal rigidity and the Kernig and Brudzinski signs were present. Laboratory examinations showed a WBC count of 9000/mm3 with 75% neutrophils, fibrinogen of 750 mgi 100 ml, and ESR of 45 mm/h. Lumbar puncture yielded turbid CSF containing 2900 white cells/mm3, of which 87% were neutrophils and 10% lymphocytes. Protein was 56 mg/lOO ml, glucose 53 mg/lOO ml (serum glucose: 95 mg/lOO ml). lactate 2.1 meq/l. Gram stain and latex test for ~t~~p~~)~t~~,~u~~ ~~~1~~~1~~~1~~~. ,~~~i.s.~~~i~iineni~?piti~:i;. ~~~~~i~J?f~i~L~*s i~~ueI?~~~~~type B and ,~~~i~p~(~~~~~,~~~~ u~~~i~ff~-
174 tier
were negative, as was the CSF culture. The tcmperature rose to 39°C with a low pulse rate of bX/min 24 h later. He had developed diplopia and ptosis of the right eye caused by a partial paralysis of the oculomotor nerve. A second lumbar puncture revealed 3400 white cells/mm”, 75% neutrophils and 15% lymphocytes. Protein was 152 mg/lOO ml, glucose 1.5mg/lOO ml (serumglucase 95 mg/ 100 ml), lactate 9 meq.11. Gram stain and latex test remained negative. Therapy with i.v. penicillin G (4 million units, 4 hourly) was started. CSF culture identified a Gram-negative coccobacillus, later identified as Kirrgel/u h-irqw. Blood cultures as well as viral serology. including HIV, were negative. The ratio of T- helper to T-suppressor lymphocytes was 0.92. A throat swab yielded Grarnpositive cocci. Stomatological and otorhinolaryngological examinations were normal. A mild thoracic folliculitis was noted. Chest X-ray was normal. Ultrasonography of the heart did not reveal valvular vegetations. Bone scint~graphy (~~“‘TC-~DP) and the human polyclon~il imrnunog~ob~~li~~scintigraphy (‘~“‘TC-HlG) failed to reveal any site of bone or joint infection. CT-scan of the brain before and after administration of a standard contrast bolus did not disclose the cause of oculotnotor palsy. The patient showed slow but steady clinical improvement. He became non-febrile after 2 days. After I4 days the intravenous antibiotic therapy was discontinued and the patient was discharged from hospital. The oculomotor paresis fully disappeared within I month.
Discussion King& kings. previously Mo~~~~ellukinguc, is a fastidious. Gram-negative coccobacillus belonging to the family of Neisseriaceae. Phenotypically and pathogenetitally Kin&h resembles the other members of the family. especially N~i.s.wriu mmingiti&~. It is distinguished from the latter by growth characteristics and biochemical reactions. Key characteristics for ~in~~~~~/~lare a positive oxidase test, negative tests for catalase, urease and ornithinedecarboxylase. and the production ofacid from gtucase and not from sorbitol [I .2]. King& kingcre is a rarely reported human pathogen. Since the organism may colonize the pharynx of humans, an endogenous source of infection is assumed in most instances. Patients with Kingdh kingac infection report a recent upper respiratory tract infection in 3 I % of cases. The most common presentations of infection are septic
arthritis, endocarditis and bacteremia. Infections have occured in immunocompetent as well as in immunocomprotnised hosts. with a majority of reported cases involving infants (70%) [2.3]. This case is the third report of meningitis. The first was a 21-month-old White girl who presented with a transient hemiparesis. Her meningitis was complicated by bilateral infarction of the basal ganglia. She recovered with few if any neurological sequelae [4f. The second case was a 22-year-old Black woman with a history of sickle cell anemia. without complications [S]. In our patient a temperature-pulse dissociation was noted. Although this sign is not uncommon in other bacterial meningitides, it has not been mentioned in the other cases of Kitzgrllr kinguc meningitis [6]. Initially, CSF glucose and protein were normal. This might be attributed to the antibiotic therapy given before admission. The ophthalmoplegia in our patient and the infarctions ofthe basal ganglia in the first reported patient with K~~‘~~~//~~ kj~~~~~~~ Ineningitis are both signs that indicate the presence of basal meningitis. Contrast enhanced CT scan failed to disclose an exudate in the basal meningeal spaces in our patient. However. no double dose of contrast was used as may sometimes be necessary to prove such an exudate [7]. The possibly predominant involvement of the basal meninges by Kin&h kingw requires confirmation by future observations. Kirzgel/a kingur is susceptible to a wide variety of antibiotics. including penicillin, ampicillin, cephaiosporin, ~~mitloglycoside, chloramphenicol and tritnethoprim-suIfamethoxazole. Only resistance to clitldamycin is known. The standard recommended therapy includes either penicillin or ampicillin [2,3]. Our patient responded to a standard therapy of penicillin G of 2 weeks duration. The 2 other cases were successfully treated with ampicillin for a period of 2 weeks initially combined with chloramphenicol and moxalactam, respectively.
References Graham, D.R. and Band. J.D.. Thornsberry, C., Ho&s, D.G. and Weaver, R.E. (1990) Infections caused by .Mora.wllu, Morcc.wllcr urc4di.r. Morrrsrllr-like groups M-S and M-6 and Kiqy//cl liing~rr~in the United States. 1953- 1980. Rev. Infect. Dis., 12: 423-431. De Groot. R., Clover, D., Clausen. C.. Smith, A.L. and Wilson, C.B. (198X) Bone and joint infections caused by k’ingel/u kir7gw: six cases and review of the literature. Rev. Infect. Dis.. 5: 99% 1004. Morrison, V.A. and Wagner, K.F. (1989) Clinical manifesta-
175 tions of Kingeh kingrw infections: case report and review. Rev. Infect. Dis.. 5: 776-~782. 4 Walterspiel, J.N. ( 1983) Kingclh kingur meningitis with bilatera1 infarcts of the basal ganglia. Infection, 6: 307-309. 5 Toshniwal. R.. Draghi. T.C.. Kocka. F.E. and Kallick. CA. (1986) Manifestation of Kingcliu kingcrc infections in adults: resemblance to iV&st&cl infections. Diagn. Microbial. Infect. Dis.. 5: 8 145.
6 Walton, .I. (IWS) Diseases of the meninges. In: Walton. J. (Ed.), Brain’s Disease of the Nervous System. 9th edn., Oxford Llniversity Press. New York. pp. 237 -249. 7 Sarwar. M.. Falkoff. G. and Nascem, M. (1986) Radiologic techniques in the diagnsosis of CNS infections. Neurol. Clin. 4: 41 4’.
Case report
~~~geZZ~kingae, a rare cause of bacterial meningitis J. Van Erps”. E. Schmedding’, A. Naessens’ and B. Keymeulen”
(Received (Revised.
19 August,
1991)
received 21 October,
(Accepted
21 October.
1991)
1991)
Meningitis (bacterial): Kingella kingae
KC-y itwCls:
Summary
A male adolescent with a history of pharyngitis developed meningitis due to King&h kingur. This is a Gram-negative coccobacillus belonging to the family of Neisseriaceae. It is a rarely reported human pathogen. from which only 2 cases of meningitis have been described up to the present day. Our patient developed ophthalmoplegia. suggestive of basal meningitis. He was treated with penicillin G and recovered completely.
Case report
Introduction
a Gram-negative microorganism belonging to the family of Neisseriaceae, is a rarely reported human pathogen. It is occasionally isolated from the nasopharynx in asymptomatic adults. During the last 10 years. an increasing number of reports concerning this bacterial species have been published, and its possibly septic character has been underlined in various infections, such as arthritis, osteomyelitis. endocarditis and bacteremia. Up to now, only 2 cases of meningitis have been pliblished, one in an infant and the other in an adult with sickle cell anemia. In this article we describe the first case of meningitis in a young and otherwise healthy adolescent. Kirtgdiu
kingm.
Cit~~cs~~oftr~~,~~
Medicine, 101.
Academic
B-1090
477.6428.
lo:
Dr.
.fodnna
Hospital.
Brussels.
Van Erps,
Vrije Universiteit
Belgium.
Tel.:
Department
of internal
Brussel, Laarbeeklaan
32-2-477.41.11;
Fax:
32-2-
A previously healthy 17-year-old Belgian man was referred to our hospital because of increasing frontal headache, neckpain and vomiting for 2 days. Antibiotic therapy, consisting of amoxycillin. had been started the day before admission. A week prior to his admission, he had symptoms which were interpreted as a common cold. Physical examination revealed a moderately ill patient, with photophobia. Body temperature was 37.3”C, blood pressure 130180 mm Hg and pulse rate 4O/min. He had nuchal rigidity and the Kernig and Brudzinski signs were present. Laboratory examinations showed a WBC count of 9000/mm3 with 75% neutrophils, fibrinogen of 750 mgi 100 ml, and ESR of 45 mm/h. Lumbar puncture yielded turbid CSF containing 2900 white cells/mm3, of which 87% were neutrophils and 10% lymphocytes. Protein was 56 mg/lOO ml, glucose 53 mg/lOO ml (serum glucose: 95 mg/lOO ml). lactate 2.1 meq/l. Gram stain and latex test for ~t~~p~~)~t~~,~u~~ ~~~1~~~1~~~1~~~. ,~~~i.s.~~~i~iineni~?piti~:i;. ~~~~~i~J?f~i~L~*s i~~ueI?~~~~~type B and ,~~~i~p~(~~~~~,~~~~ u~~~i~ff~-
174 tier
were negative, as was the CSF culture. The tcmperature rose to 39°C with a low pulse rate of bX/min 24 h later. He had developed diplopia and ptosis of the right eye caused by a partial paralysis of the oculomotor nerve. A second lumbar puncture revealed 3400 white cells/mm”, 75% neutrophils and 15% lymphocytes. Protein was 152 mg/lOO ml, glucose 1.5mg/lOO ml (serumglucase 95 mg/ 100 ml), lactate 9 meq.11. Gram stain and latex test remained negative. Therapy with i.v. penicillin G (4 million units, 4 hourly) was started. CSF culture identified a Gram-negative coccobacillus, later identified as Kirrgel/u h-irqw. Blood cultures as well as viral serology. including HIV, were negative. The ratio of T- helper to T-suppressor lymphocytes was 0.92. A throat swab yielded Grarnpositive cocci. Stomatological and otorhinolaryngological examinations were normal. A mild thoracic folliculitis was noted. Chest X-ray was normal. Ultrasonography of the heart did not reveal valvular vegetations. Bone scint~graphy (~~“‘TC-~DP) and the human polyclon~il imrnunog~ob~~li~~scintigraphy (‘~“‘TC-HlG) failed to reveal any site of bone or joint infection. CT-scan of the brain before and after administration of a standard contrast bolus did not disclose the cause of oculotnotor palsy. The patient showed slow but steady clinical improvement. He became non-febrile after 2 days. After I4 days the intravenous antibiotic therapy was discontinued and the patient was discharged from hospital. The oculomotor paresis fully disappeared within I month.
Discussion King& kings. previously Mo~~~~ellukinguc, is a fastidious. Gram-negative coccobacillus belonging to the family of Neisseriaceae. Phenotypically and pathogenetitally Kin&h resembles the other members of the family. especially N~i.s.wriu mmingiti&~. It is distinguished from the latter by growth characteristics and biochemical reactions. Key characteristics for ~in~~~~~/~lare a positive oxidase test, negative tests for catalase, urease and ornithinedecarboxylase. and the production ofacid from gtucase and not from sorbitol [I .2]. King& kingcre is a rarely reported human pathogen. Since the organism may colonize the pharynx of humans, an endogenous source of infection is assumed in most instances. Patients with Kingdh kingac infection report a recent upper respiratory tract infection in 3 I % of cases. The most common presentations of infection are septic
arthritis, endocarditis and bacteremia. Infections have occured in immunocompetent as well as in immunocomprotnised hosts. with a majority of reported cases involving infants (70%) [2.3]. This case is the third report of meningitis. The first was a 21-month-old White girl who presented with a transient hemiparesis. Her meningitis was complicated by bilateral infarction of the basal ganglia. She recovered with few if any neurological sequelae [4f. The second case was a 22-year-old Black woman with a history of sickle cell anemia. without complications [S]. In our patient a temperature-pulse dissociation was noted. Although this sign is not uncommon in other bacterial meningitides, it has not been mentioned in the other cases of Kitzgrllr kinguc meningitis [6]. Initially, CSF glucose and protein were normal. This might be attributed to the antibiotic therapy given before admission. The ophthalmoplegia in our patient and the infarctions ofthe basal ganglia in the first reported patient with K~~‘~~~//~~ kj~~~~~~~ Ineningitis are both signs that indicate the presence of basal meningitis. Contrast enhanced CT scan failed to disclose an exudate in the basal meningeal spaces in our patient. However. no double dose of contrast was used as may sometimes be necessary to prove such an exudate [7]. The possibly predominant involvement of the basal meninges by Kin&h kingw requires confirmation by future observations. Kirzgel/a kingur is susceptible to a wide variety of antibiotics. including penicillin, ampicillin, cephaiosporin, ~~mitloglycoside, chloramphenicol and tritnethoprim-suIfamethoxazole. Only resistance to clitldamycin is known. The standard recommended therapy includes either penicillin or ampicillin [2,3]. Our patient responded to a standard therapy of penicillin G of 2 weeks duration. The 2 other cases were successfully treated with ampicillin for a period of 2 weeks initially combined with chloramphenicol and moxalactam, respectively.
References Graham, D.R. and Band. J.D.. Thornsberry, C., Ho&s, D.G. and Weaver, R.E. (1990) Infections caused by .Mora.wllu, Morcc.wllcr urc4di.r. Morrrsrllr-like groups M-S and M-6 and Kiqy//cl liing~rr~in the United States. 1953- 1980. Rev. Infect. Dis., 12: 423-431. De Groot. R., Clover, D., Clausen. C.. Smith, A.L. and Wilson, C.B. (198X) Bone and joint infections caused by k’ingel/u kir7gw: six cases and review of the literature. Rev. Infect. Dis.. 5: 99% 1004. Morrison, V.A. and Wagner, K.F. (1989) Clinical manifesta-
175 tions of Kingeh kingrw infections: case report and review. Rev. Infect. Dis.. 5: 776-~782. 4 Walterspiel, J.N. ( 1983) Kingclh kingur meningitis with bilatera1 infarcts of the basal ganglia. Infection, 6: 307-309. 5 Toshniwal. R.. Draghi. T.C.. Kocka. F.E. and Kallick. CA. (1986) Manifestation of Kingcliu kingcrc infections in adults: resemblance to iV&st&cl infections. Diagn. Microbial. Infect. Dis.. 5: 8 145.
6 Walton, .I. (IWS) Diseases of the meninges. In: Walton. J. (Ed.), Brain’s Disease of the Nervous System. 9th edn., Oxford Llniversity Press. New York. pp. 237 -249. 7 Sarwar. M.. Falkoff. G. and Nascem, M. (1986) Radiologic techniques in the diagnsosis of CNS infections. Neurol. Clin. 4: 41 4’.
