WordNet

preeminence in a particular category or group or field; "the lion is the king of beasts"
(chess) the weakest but the most important piece
a checker that has been moved to the opponents first row where it is promoted to a piece that is free to move either forward or backward
one of the four playing cards in a deck bearing the picture of a king
a male sovereign; ruler of a kingdom (同)male monarch, Rex
a competitor who holds a preeminent position (同)queen, world-beater

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『王』,国王 / 王にたとえられる人(物),…王,大立て者 / (カードの)キング / (チェスの)キング,王将

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2014/11/12 02:22:44」(JST)

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Kingella kingae is a species of Gram-negative aerobic coccobacilli. First isolated in 1960, it was not recognized as a significant cause of infection in young children until the 1990s, when culture techniques had improved enough for it to be recognized. It is best known as a cause of septic arthritis, osteomyelitis, spondylodiscitis, bacteraemia, and endocarditis, and less frequently lower respiratory tract infections and meningitis.^[1]

There are four species of Kingella: K. kingae, the most common, is part of the bacterial flora of the throat in young children and is transmitted from child to child. When it causes disease, the clinical presentation is often subtle and preceded by a recent history of stomatitis or upper respiratory infection. Other species are K. indologenes, K. denitrificans both causing endocarditis, and K. oralis found in dental plaque.

One notable exception is in cases of endocarditis (heart valve infection), which can be more refractory to treatment. K. kingae is the fifth member of the HACEK group of fastidious Gram-negative bacteria that cause endocarditis. Routine laboratory tests may be normal because the organism is difficult to culture. Inoculating the fluid from infected joints directly into blood culture vials can enhance the chances of an accurate culture, but extended culture times are not helpful.^[2]

The organism has also been known as Moraxella kingae.

K. kingae is oxidase-positive, catalase-negative, and beta-hemolytic.

Mechanism of infection

Kingella kingae is thought to begin infection by colonizing the pharynx, crossing the epithelium by using an RTX toxin, and entering the circulation and reaching deeper tissues, such as bones and joints.

K. kingae expresses type IV pili, which allow for enhanced adhesion to respiratory epithelial and synovial cells and thus increased likelihood of colonization. These pili have also been shown to be reduced in number as pathogenesis progresses. σ54 regulates the transcription of pilA1, a major pilus subunit. PilS and PilR, regulatory transcription factors best known from the Pseudomonas aeruginosa pilus system, also may regulate pilA expression. High levels of type IV pili on K.kingae are associated with spreading/corroding colony types, while low levels of type IV pili are associated with nonspreading/noncorroding colony types of K. kingae.^[3] The three different types of populations are: spreading/corroding (with high-density pilation), nonspreading/noncorroding colonies (low density pilation), and domed colonies (no pilation, and thus no adherence to epithelium). Generally, respiratory and nonendocarditis infections tend to be highly piliated, while joint fluid, bone, and endocarditis blood isolates are less piliated, if at all.^[4]

Spondylodiscitis

Children under three years of age may become infected with K.kingae and develop spondylodiscitis. Typical symptoms include back pain, abdominal pain, and damage to the bones and joints. It generally targets the lumbar region of the spinal cord, and the only true way of diagnosing it is through biopsy or needle aspiration, as blood plate growth gives many false negatives.^[5]

Osteomyelitis

Osteomyelitis occurs in previously healthy children. The infection rate is poorly documented, thus the illness tends to go underdiagnosed. K. kingae can be transmitted person to person in rare cases. Diagnostic tools include low-grade fever, elevated inflammatory markers (ESR and CRP), but white blood cell counts are generally unreliable since they vary among infected patients. K. kingae infections are generally comcomitant with upper respiratory diseases or stomatitis, since disrupted respiratory or buccal mucosa is likely to facilitate bacterial invasion and hematogenous dissemination.

The cause of osteoarticular infections is frequently not identified. Less than 15% of K. kingae-positive clinical specimens reveal organisms on Gram stain. ^[6] Fortunately, K. kingae is readily treatable with a wide variety of antibiotics, such as beta-lactams, tetracyclines, erythromycin, and fluoroquinolones.^[7] It shows low minimum inhibitory concentrations for penicillins, rifampicin, and azithromycin. Multiple studies have shown that inoculating synovial fluid or bone samples directly into blood culture bottles substantially increases the detection of K kingae compared with direct plating of specimens on solid media.

As an oropharyngeal colonizer, K kingae is transmitted by respiratory secretions, saliva, and potentially oral contact with contaminated objects. Recent studies suggest K. kingae strains may demonstrate varying degrees of pathogenicity, which could support the person-to-person transfer of pathogenic K. kingae. Infection has been shown to have high prevalence in the autumn and winter months.^[8]

Adult infections

K.kingae infections are quite rare in adults, but they do occur in immunocompromised patients. Poor oral hygiene, pharyngitis, and mucosal ulceration are also predisposing factors for infection. The infection can occur in the respiratory or urinary tracts, as it is a part of the normal flora in those two areas, and will develop into septicemia or septic arthritis.^[9] Most K. kingae are sensitive to beta-lactam antibiotics, but reports describe strains producing beta-lactamases.^[10] Options include aminoglycosides, macrolides and fluoroquinolones.

References

^ Yagupsky P. Kingella kingae: from medical rarity to an emerging paediatric pathogen. Lancet Infectious Disease 2004 Jun;4(6):358-67.
^ Petti CA; Bhally HS; Weinstein MP; Joho K; Wakefield T; Reller LB; Carroll KC. Utility of extended blood culture incubation for isolation of haemophilus, actinobacillus, cardiobacterium, eikenella, and kingella organisms: a retrospective multicenter evaluation. Journal of Clinical Microbiology. 2006 Jan;44(1):257-9.
^ Kehl-Fie, T.E. et al (2009) Expression of Kingella kingae Type IV Pili Is Regulated by σ54, PilS, and PilR. J. Bacteriol. 191(15): 4976-86.
^ Kehl-Fie, T.E. et al. (2010) Examination of Type IV Pilus Expression and Pilus-Associated Phenotypes in Kingella kingae Clinical Isolates. Infect Immun. 78(4): 1692-9.
^ Ceroni, D. et al. (2010) Kingella kingae spondylodiscitis in young children: toward a new approach for bacteriological investigations? A preliminary report. J Child Orthop. 4(2):173-175.
^ Kiang, K.M. et al. (2005) Outbreak of Osteomyelitis/Septic Arthritis Caused by Kingella kingae Among Child Care Center Attendees. Pediatrics. 116(2): e206-13.
^ Petti CA; Bhally HS; Weinstein MP; Joho K; Wakefield T; Reller LB; Carroll KC. Utility of extended blood culture incubation for isolation of haemophilus, actinobacillus, cardiobacterium, eikenella, and kingella organisms: a retrospective multicenter evaluation. Journal of Clinical Microbiology. 2006 Jan;44(1):257-9.
^ Kiang, K.M. et al. (2005) Outbreak of Osteomyelitis/Septic Arthritis Caused by Kingella kingae Among Child Care Center Attendees. Pediatrics. 116(2): e206-13.
^ Ramana, K.V. and Mohanty, S.K. (2009) An adult case of urinary tract infection with Kingella kingae: a case report. J Med Case Reports. 3: 7236.
^ Anushree Banerjee et al. Characterization of TEM-1 β-Lactamase-Producing Kingella kingae Clinical Isolates. Antimicrob. Agents Chemother. 2013, 57: 4300-6

UpToDate Contents

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1. 細菌性関節炎：幼児および小児における疫学、病因、および微生物学 bacterial arthritis epidemiology pathogenesis and microbiology in infants and children
2. 小児における血行性骨髄炎：マネージメント hematogenous osteomyelitis in children management
3. 小児における血行性骨髄炎：疫学、病因、および微生物学 hematogenous osteomyelitis in children epidemiology pathogenesis and microbiology
4. 細菌性関節炎：幼児および小児の治療および転帰 bacterial arthritis treatment and outcome in infants and children
5. 小児における血行性骨髄炎：評価および診断 hematogenous osteomyelitis in children evaluation and diagnosis

English Journal

Kingella kingae septic arthritis in children: recognising an elusive pathogen.

Williams N, Cooper C, Cundy P.Author information Department of Orthopaedics, Women's and Children's Hospital, 72 King William Rd, North Adelaide, SA, 5006, Australia, Nicole.Williams3@health.sa.gov.au.AbstractPURPOSE: Kingella kingae is an increasingly identified cause of musculoskeletal infections in young children. We report our experience with a recently developed polymerase chain reaction (PCR) method and review the clinical course of children diagnosed with K. kingae septic arthritis in a tertiary referral paediatric hospital.
Journal of children's orthopaedics.J Child Orthop.2014 Jan 23. [Epub ahead of print]
PURPOSE: Kingella kingae is an increasingly identified cause of musculoskeletal infections in young children. We report our experience with a recently developed polymerase chain reaction (PCR) method and review the clinical course of children diagnosed with K. kingae septic arthritis in a tertiary r
PMID 24488842

Recent lessons for the management of bone and joint infections.

Kaplan SL.Author information Section of Pediatric Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA; Infectious Disease Service, Texas Children's Hospital, Feigin Center, Suite 1150, 1102 Bates Ave., Houston, TX 77030, USA. Electronic address: skaplan@bcm.edu.AbstractThe epidemiology and clinical manifestations of osteoarticular infections are changing primarily as a result of the emergence of community-acquired methicillin-resistant Staphylococcus aureus infections. Multifocal disease, venous thrombosis and pathologic fractures are manifestations of CA-MRSA osteomyelitis. MRI is the diagnostic imaging modality of choice for musculoskeletal infections. Nafcillin/oxacillin or cefazolin remains the antibiotic of choice for treating infections caused by MSSA. A β-lactam antibiotic is recommended for Kingella kingae. Vancomycin and clindamycin are the first line agents for treating osteomyelitis caused by CA-MRSA. A short course of parenteral antibiotics followed by appropriate oral antibiotics is equivalent to total course of parenteral antibiotics for most patients and avoids the risks associated with PICCs. Surgical drainage of subperiosteal abscesses and surrounding pyomyositis is common with S. aureus clones currently circulating. Collaboration with hematologists for managing patients with venous thromboses is recommended.
The Journal of infection.J Infect.2014 Jan;68 Suppl 1:S51-6. doi: 10.1016/j.jinf.2013.09.014. Epub 2013 Oct 9.
The epidemiology and clinical manifestations of osteoarticular infections are changing primarily as a result of the emergence of community-acquired methicillin-resistant Staphylococcus aureus infections. Multifocal disease, venous thrombosis and pathologic fractures are manifestations of CA-MRSA ost
PMID 24119927

Unusually severe cases of Kingella kingae osteoarticular infections in children.

Mallet C, Ceroni D, Litzelmann E, Dubois-Ferriere V, Lorrot M, Bonacorsi S, Mazda K, Ilharreborde B.Author information From the *Pediatric Orthopedic Department, Robert Debré University Hospital, Paris, France; †Pediatric Orthopedic Department, University Hospital of Geneva, Geneva, Switzerland; ‡Pediatric Department; and §Microbiology Department, Robert Debré University Hospital, Paris, France.AbstractBACKGROUNDS: With the development of molecular biology and specific polymerase chain reaction, Kingella kingae has become the primary diagnosis of osteoarticular infections in young children. Clinical features of these osteoarticular infections are typically mild, and outcome is almost always favorable. We report a series of unusually severe cases of K. kingae osteoarticular infections.
The Pediatric infectious disease journal.Pediatr Infect Dis J.2014 Jan;33(1):1-4. doi: 10.1097/INF.0b013e3182a22cc6.
BACKGROUNDS: With the development of molecular biology and specific polymerase chain reaction, Kingella kingae has become the primary diagnosis of osteoarticular infections in young children. Clinical features of these osteoarticular infections are typically mild, and outcome is almost always favora
PMID 23856785