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British Journal of Radiology (2006) 79, e181-e183
© 2006 British Institute of Radiology
doi: 10.1259/bjr/35629425
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Case report

Kingella kingae spondylodiscitis in a child

H J S Bining, BSc(Hon), MD, FRCP(C) 1 G Saigal, MBBS 2 J Chankowsky, MD, FRCP(C) 1 E E Rubin, MDCM, FRCP(C) 3 and E B Camlioglu, BSc, MSc, MD, FRCP(C) 1

1 Department of Diagnostic Radiology, McGill University, 1650 Cedar Avenue, Montreal, Quebec, H3G 1A4, Canada, 2 Department of Diagnostic Radiology, University of Miami, 1611 NW 12th Avenue, West Wing 279, Miami, Florida 33129, USA, 3 Department of Pediatrics, Division of Infectious Diseases and Department of Microbiology, Montreal Children's Hospital of the McGill University Health Centre, 2300 Tupper Street, Montreal, Quebec, H3H 1P3, Canada

Correspondence: Dr Harjinder John Singh Bining, Department of Diagnostic Radiology, McGill University, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada. E-mail: hjsbining{at}yahoo.ca.


   Abstract
Top
 Abstract
Introduction
 Case report
 Discussion
 References
 
Most osteoarticular infections in children are due to Staphylococcus aureus. In this case, the isolation of Kingella kingae by image guided disc aspiration resulted in modification and optimization of treatment. We take a look at a case of spondylodiscitis in a young child and review some of the current literature with regards to Kingella kingae infections.


   Introduction
Top
 Abstract
 Introduction
Case report
 Discussion
 References
 
The aetiology of discitis in children includes both infectious and inflammatory causes, which, respectively, require either prolonged antibiotic therapy or anti-inflammatories and rest. In approximately 50% of isolates there is a bacterium isolated, with Staphylococcus aureus being the most common, followed by isolates of pneumococci and gram negative organisms [1]. Therefore, it is important to clarify the diagnosis in order to isolate the offending bacteria and to treat with appropriate therapy.

Kingella kingae is an increasingly recognized bacterium responsible for variety of infections, including spondylodiscitis. It usually runs an indolent, benign course that requires a high clinical suspicion for diagnosis. We report a case of spondylodiscitis in a young child.


   Case report
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 Abstract
 Introduction
 Case report
Discussion
 References
 
A 6-year-old Aboriginal boy presented with a 3 week history of back pain with inability to ambulate and sit up. On examination, he had fever of 39.3°C of 1 day's duration and lower lumbosacral pain on palpation. The neurological examination was otherwise normal. Laboratory tests revealed an erythrocyte sedimentation rate (ESR) of 50 (normal range 3–13 mm h–1), C-reactive protein (CRP) of >96 (normal <6 mg l–1) and a negative PPD (purified protein derivative of tuberculin).

An MRI was performed which demonstrated loss of normal T2 hyperintensity in the L4–L5 disc with adjacent vertebral body T2 hyperintensity and minimal enhancement, both indicative of bone marrow oedema (GoFigures 1 and 2Go). These findings were suggestive of discitis/osteomyelitis.


Figure 1
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  		Figure 1. (a) Sagittal T1 weighted image demonstrating decreased signal abnormality involving the lower half of the L4 and the upper half of the L5 vertebral bodies (white stars). (b) Sagittal T1 weighted post-contrast image showing the end plate irregularity and enhancement (arrow).

 

Figure 2
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  		Figure 2. SagittalT2 weighted image showing mild disc space reduction at the L4–L5 level, with a posterior disc bulge (black arrow) and loss of the normal T2 hyperintensity (white arrow).

 
Following the MRI and in order to exclude an unusual infection (such as mycobacterium tuberculosis), L4–L5 disc aspiration was performed under fluoroscopic guidance. The biopsy was performed from a posterolateral extradural approach, using an 18 G guiding needle through which a 22 G spinal needle was inserted. Disc aspirate demonstrated Kingella kingae on culture. There was no growth of acid fast bacilli (mycobacterium tuberculosis) or fungi. Blood cultures were also negative.

Patient responded well to intravenous ceftriaxone and improved clinically and radiologically on follow up examinations.


   Discussion
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 Abstract
 Introduction
 Case report
 Discussion
References
 
Intervertebral disc infections arise primarily in children under the age of 5 years [1]. Typical radiographic findings are not detectable until 2–4 weeks after the onset of symptoms [1]. Initially, narrowing of the disc space occurs followed by destruction of the adjacent cartilaginous vertebral end plates, with subsequent disc herniation into the vertebral body or vertebral body collapse [1]. Some of the symptoms demonstrated in young patients with spondylodiscitis include limping, lumbar pain, back stiffness, refusal to sit or walk, increased irritability or crying and neurological or abdominal symptoms [2, 3].

Non-tuberculous spondylodiscitis (NTS) is responsible for roughly 2% of all childhood bone infections [4]. Garron et al reported that Staphylococcus aureus was the most common organism [5], present in 55% of disc aspirates. Kingella kingae was the second most common organism, grown from 27% of disc aspirates [4]. Other rare organisms responsible for spondylodiscitis include Staphylococcus epidermidis, Clostridium clostridiiforme, Coxiella burnetii, Enterobacteriaciae and Streptococcus pneumoniae [4, 6].

Kingella kingae was discovered in 1960 by Elizabeth King and was described subsequently as a non-motile, aerobic, fastidious, Gram-negative coccobacillus [7]. It is found to be a normal inhabitant of the upper respiratory tract with demonstrated carriage rates of nearly 75% in children over 6 months of age at some time [8]. Children with invasive Kingella kingae infections have often had a recent history of upper respiratory tract infection or stomatitis [7, 9–11]. There is evidence that child-to-child transmission of Kingella kingae occurs among young children [2]. Nearly 90% of invasive Kingella kingae infections occur in children younger than 5 years of age, and over 60% occur below the age of 2 years [12]. Kingella kingae is mainly responsible for osteoarticular infections, occult bacteraemia, lower respiratory tract infections and endocarditis [2, 10, 13]. There are reports of rare cases of meningitis, corneal ulcers, endophthalmitis and soft tissue infections [7].

MRI should be utilized routinely when spondylodiscitis is suspected. It assists in primary diagnosis and permits observation for abscess development and for disc and bone damage [4]. In this case and other similar scenarios, it is important to obtain a disc space aspirate for culture in order to exclude tuberculous spondylodiscitis and to treat with appropriate antibiotics [6, 10]. Disc aspiration can also be useful in selected cases which do not respond to antibiotics, cases with negative blood cultures and cases with other suspected unusual organisms.

Kingella kingae is likely an under-recognized pathogen in children [11]. The organism is being recognized more frequently due to better culture techniques and greater awareness of its presence by laboratories [2]. The use of blood culture media significantly improves the rate of isolation from sterile body fluids [11]. Therefore, it is important that the radiologist procuring the biopsy properly inoculates the specimen into a blood culture bottle.

The multicentre trial by Ring et al concluded that initial immobilization and intravenous antibiotics in paediatric infectious spondylitis was responsible for more rapid recovery [14]. Kingella kingae is highly susceptible to penicillin, ampicillin, second and third-generation cephalosporins, macrolides, co-trimoxazole, ciprofloxacin, tetracycline and chloramphenicol [2]. The treatment duration recommended is between 3 weeks and 12 weeks [2].

Most invasive Kingella kingae infections, including spondylodiscitis, follow a benign clinical course after administration of antibiotic therapy [2]. Some of the proposed natural outcomes of NTS are disc fibrosis or vertebral fusion [4].

In conclusion, the index of suspicion for spondylodiscitis should be high in children with back pain, since this occurs so infrequently in children. MRI is the ideal examination for evaluating and diagnosing this condition. Upon diagnosis, a disc biopsy or aspirate using blood culture bottles can be performed in certain situations, given that not all infections are caused by Staphylococci. Early detection and appropriate antibiotic treatment can prevent a more devastating course of these infections in children.

Received for publication September 28, 2005. Revision received January 21, 2006. Accepted for publication January 25, 2006.


   References
Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 

  1. Feigin RD. Textbook of pediatric infectious diseases. 5th edn. Philadelphia, PA: Saunders, 2004
  2. Yagupsky P. Kingella kingae: from medical rarity to an emerging paediatric pathogen. Lancet Infect Dis 2004;4:358–67.[CrossRef][Medline]
  3. Woolfrey BF, Lally RT, Faville RJ. Intervertebral diskitis caused by Kingella kingae. Am J Clin Pathol 1986;85:745–9.[Medline]
  4. Garron E, Viehweger E, Launay F, Guillaume JM, Jouve JL, Bollini G. Nontuberculous spondylodiscitis in children. J Pediatr Orthop 2002;22:321–8.[CrossRef][Medline]
  5. Amir J, Shockelford PG. Kingella kingae intervertebral disk infection. J Clin Microbiol 1991;29:1083–6.[Abstract/Free Full Text]
  6. Brook I. Two cases of diskitis attributable to anaerobic bacteria in children. Pediatrics 2001;107:E26
  7. Dodman T, Robson J, Pincus D. Kingella kingae infections in children. J Paediatr Child Health 2000;36:87–90.[CrossRef][Medline]
  8. Yagupsky P, Dagan R, Prajgrod F, Merires M. Respiratory carriage of Kingella kingae among healthy children. Pediatr Infect Dis J 1995;14:673–8.[Medline]
  9. Yagupsky P, Dagan R. Kingella kingae: an emerging cause of invasive infections in young children. Clin Infect Dis 1997;24:860–6.[Medline]
  10. Claesson B, Falsen E, Kjellman B. Kingella kingae infections: a review and a presentation of data from 10 Swedish cases. Scand J Infect Dis 1985;17:233–43.[Medline]
  11. La Scola B, Iorgulescu I, Bollini G. Five cases of Kingella kingae skeletal infection in a French hospital. Eur J Clin Microbiol Infect Dis 1998;17:512–5.[Medline]
  12. Yagupsky P, Dagan R, Howard CB, Einhorn M, Kassis I, Simu A. Clinical features and epidemiology of invasive Kingella kingae infections in southern Israel. Pediatrics 1993;92:800–4.[Abstract/Free Full Text]
  13. Odum L, Jensen KT, Slotsbjerg TD. Endocarditis due to Kingella kingae. Eur J Clin Microbiol 1984;3:263–6.[CrossRef][Medline]
  14. Ring D, Johnston CE 2nd, Wenger DR. Pyogenic infectious spondylitis in children: the convergence of discitis and vertebral osteomyelitis. J Pediatr Orthop 1995;15:652–60.[Medline]



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