Kingella kingae is a fastidious gram-negative
coccobacillus that colonizes the respiratory and oropharyngeal tract in children. K. kingae occasionally causes invasive disease, primarily
osteomyelitis/septic arthritis in young children, bacteremia in infants, and
endocarditis in school-aged children and adults.1- 8 Although
diagnosis of this organism frequently is missed, invasive disease is uncommon.
Only sporadic, non-epidemiologically linked cases have been reported previously.
In October 2003, the Minnesota Department of Health (MDH) investigated a cluster
of two confirmed cases and one probable case of osteomyelitis/septic arthritis
caused by K. kingae among children aged 17-21 months
attending the same toddler classroom in a day care center. All reported within
the same week with onset of fever, preceding or concurrent upper respiratory
illness (URI), and refusal to bear weight on the affected limb. This report
summarizes these cases and describes the epidemiologic investigation of the
day care center. The findings underscore the need for clinicians and laboratorians
to consider K. kingae infection in young children
with Gram stain–negative or culture-negative skeletal infections.
Case 1. In mid-October 2003, a boy aged 21
months was taken to his pediatrician after 6 days of worsening limp. He had
a history of prematurity (32 weeks' gestation), reflux disease, reactive-airway
disease, and eczema, but was otherwise healthy with no history of recent antibiotic
use. Nine days before, he had an isolated temperature reaching 103°F (39.4°C),
which resolved with acetaminophen. His white blood cell (WBC) count and erythrocyte
sedimentation rate (ESR) were normal. A right hip radiograph showed an abnormality
in the proximal femur, which was diagnosed as a possible fracture. The patient's
limp deteriorated to a crawl, and he underwent surgery 7 days after the initial
examination. Femoral neck osteomyelitis and hip septic arthritis were diagnosed.
At the time of surgery, his WBC count and ESR were elevated (17,200 cells/mm3 and 51 mm/hr, respectively [normal ranges: 6,000-17,000 cells/mm3 and 0-10 mm/hr, respectively]) and C-reactive protein (CRP) was normal
(<0.5 mg/dL). Gram stain of synovial fluid showed several WBCs but no organisms;
synovial fluid and bone cultures were positive for K. kingae 5 days later.
Case 2. In mid-October, a previously healthy
girl aged 20 months who had completed a 14-day course of amoxicillin/clavulanic
acid for otitis media in early October was reported with irritability, refusal
to bear weight on her right foot, and a warm right ankle. During the next
few days, she had a temperature reaching 101.6°F (38.7°C), and her
right ankle became swollen and red. An MRI revealed fluid in her ankle joint.
She had a normal WBC count and slightly elevated ESR (38 mm/hr). Three days
later, she underwent surgery for ankle and subtalar septic arthritis. Gram
stain of synovial fluid was negative, but K. kingae was
identified from culture 4-5 days later.
Case 3. In mid-October, a previously healthy
boy aged 17 months with recent but transient neutropenia related to viral
illness, was taken to the emergency department with irritability, a limp of
2 days' duration, and a temperature of 102°F (38.9°C). His right ankle
was moderately warm and swollen, and radiographs were normal. His WBC was
high-normal (12,500 cells/mm3), and his CRP was slightly elevated
(1.27 mg/dL). He had synovitis and otitis media diagnosed and was administered
a 7-day course of oral amoxicillin. Although his clinical status improved,
he continued to limp after foot manipulation; MRI of his right ankle 16 days
later revealed evidence of distal tibial osteomyelitis. No specimens were
The day care staff members were interviewed, and a site visit was performed;
absentee, illness, and biting records were examined. No obvious outbreak source
was identified, and no unusual practices or behaviors were noted that could
explain this cluster of illnesses. Oropharyngeal cultures were obtained from
center staff and from children aged 0-5 years to assess K. kingae colonization. Of 122 children, 115 (94%) were cultured; 16
(14%) children were colonized with K. kingae. The
highest prevalence occurred in the toddler class (nine [45%] of 20 tested
positive; patients 1-3 tested negative, but all had received antibiotics).
The remaining seven colonized children were distributed among four classes
of older children; two were siblings of colonized children in the toddler
class. No staff or children aged <16 months were colonized.
Pulsed-field gel electrophoresis (PFGE) of the K.
kingae isolates from the two confirmed patients and from 15 of the
16 colonized children (nine toddlers and six from older classes) demonstrated
indistinguishable PFGE patterns. Antimicrobial susceptibility testing revealed
a minimum inhibitory concentration (MIC) of 0.047-0.125 µg/mL to rifampin
and a MIC of 0.004-0.047 µg/mL to penicillin.
All children (n = 20) and staff (n = six) in the toddler classroom received
a prophylactic 2-day course of rifampin, and oropharyngeal cultures were collected
again 10-14 days later. Of the nine toddlers colonized originally, three (33%)
remained positive on reculture. An additional toddler, who was initially culture-negative,
was positive for K. kingae on reculture.
R Faville, MD, S Koop, MD, Gillette Children's Hospital, St. Paul; F
Ogunmodede, MBBS, R Lynfield, MD, R Danila, PhD, B Juni, MS, D Boxrud, MS,
A Glennen, E Shade, K Penterman, Minnesota Dept of Health. K Kiang, MD, EIS
This report describes the first reported cluster of epidemiologically
linked cases of invasive K. kingae disease. The high
incidence in the toddler class and the matching PFGE pattern are consistent
with child-to-child transmission. This report also describes the first reported
attempt to use rifampin to eliminate K. kingae carriage;
this attempt proved to be moderately effective.
K. kingae constitutes part of the normal respiratory
flora in children but can cause isolated cases of invasive disease, primarily
osteomyelitis/septic arthritis (65%-75% of cases) in young children and bacteremia
(20%-30% of cases) in infants.1,2,7,8 The
majority of children who have invasive disease are previously healthy without
immunosuppressive conditions; >90% are aged <2 years.1,2,5- 8
Invasive disease is associated frequently with concomitant or precedent
URI or stomatitis3,4; disrupted
respiratory or buccal mucosa might facilitate bacterial invasion and hematogenous
dissemination. Biting might be an alternative means of introducing oropharyngeal
pathogens into the bloodstream.
The presence of K. kingae is difficult to detect
without immediate clinical suspicion. Gram stain of synovial fluid shows WBCs
but frequently is negative for organisms. Recovery of the organism in culture
is difficult because of its fastidious nature, and might require laboratories
to hold culture plates for up to 7 days. For cases described in this report,
cultures were held longer than routine laboratory protocol recommends (usually
3 days) because an atypical organism was suspected. Studies of cases in Israel
indicate that 40%-50% of culture-negative septic arthritis cases in children
aged <2 years might be attributable to K. kingae.5,8 Inoculating synovial fluid or
bony exudates directly into blood-culture bottles with a continuous monitoring
system increases the rate of K. kingae recovery substantially,
compared with direct plating of specimens on solid media.5,8 The
increased awareness and enhanced capability of laboratories to isolate this
organism might lead to an observed increase in incidence of K. kingae invasive disease.
Although limited data are available about the epidemiology and transmission
of K. kingae, the organism most likely is transmitted
through respiratory secretions and saliva. In one study of an Israeli day
care center, the monthly prevalence of K. kingae colonization
ranged from 6% to 35%, and approximately 70% of children were colonized at
some point during the 11-month study period. No invasive disease was observed.9 Subtyping by PFGE, immunoblotting, and ribotyping
of the isolates demonstrated that children were colonized continuously, or
intermittently with different subtypes over weeks to months. Two distinct
subtypes with temporal clustering represented approximately 75% of the isolates.10 In comparison, a cohort of epidemiologically unrelated
cases showed substantially more subtype variability.10 These
findings suggest person-to-person transmission within the facility.
The pattern of colonization and invasive disease described in this report
is consistent with previous studies. The indistinguishable PFGE pattern of
the isolates further indicates the person-to-person mode of K. kingae transmission among children who attend day care centers.
The incidence of invasive disease was exceptionally high among these children.
Further examination into potential risk factors and DNA sequencing of the
day care K. kingae isolates are being conducted by
The findings in this report underscore the need for clinicians to suspect
infection with K. kingae and other atypical organisms
in young children with Gram stain–negative or culture-negative skeletal
infections and for laboratorians to perform appropriate laboratory diagnostic
testing. The use of blood-culture bottles for inoculation and cultivation
of synovial fluid/bone tissue and the incubation of culture plates for ≥1
week might increase the diagnosis of pediatric skeletal infections attributed
to K. kingae.
This report is based on contributions by P Yagupsky, Clinical Microbiology
Laboratory and Pediatric Infectious Disease Unit, Soroka Univ Medical Center,
Beer-Sheva, Israel. K Marbin, Gillette Children's Hospital, St. Paul, Minnesota.
J Jorgenson, Health Science Center, Univ of Texas-San Antonio, Texas. F Tenover,
D Jernigan, Div of Healthcare Quality Promotion; M Fischer, Div of Bacterial
and Mycotic Diseases, National Center for Infectious Diseases, CDC.
Osteomyelitis/Septic Arthritis Caused by. JAMA. 2004;291(17):2065-2069. doi:10.1001/jama.291.17.2065