IMAGES IN NEUROLOGY

Global Aphasia Without Hemiparesis
Secondary to Kingella kingae Endocarditis

A

53- YEAR-OLD man
was admitted with a
2-day history of odd
behavior and increased drowsiness.
On the day of admission he suddenly lost the ability to speak. He
also had a 3-month history of lethargy, abdominal pain, and weight
loss, which had been investigated by
his general practitioner. The only abnormality found was a plasma viscosity of 2.27 mPas (normal, 1.251.72 mPas). He smoked 20 cigarettes
per day. The remainder of the history was unremarkable. On admission he was pyrexial (temperature,
38.0°C) and tachycardic with a
global aphasia without hemiparesis. There were no other abnormalities: in particular the findings of cardiovascular examination were
normal.
He had a plasma viscosity of
2.5 mPas, a C-reactive protein level
of 65 mg/L, and a positive rheumatoid factor with a titer of 1:320.
The findings of other investigations, including transthoracic echocardiogram, were all normal. Cranial magnetic resonance imaging
(Figure 1) revealed 2 discrete areas of infarction. His cerebrospinal
fluid contained 20 red cells per
cubic millimeter and 210 white
cells per cubic millimeter, 80% of
which were lymphocytes: the protein and glucose values were normal. He began treatment with
high-dose cefotaxime and acyclovir. Cerebrospinal fluid examination 2 days later revealed 185 white
cells per cubic millimeter, 0.80
neutrophils. The protein and glucose values were again normal.
Transesophageal echocardiography demonstrated vegetation on
the aortic (Figure 2) and mitral

Figure 1. A turbo spin-echo T2-weighted magnetic resonance imaging scan revealing 2 discrete areas of
cerebral infarction (arrows) in the territory of the left middle cerebral artery, separated by normal brain
tissue.

(Figure 3) valves. Blood cultures
after 14 days of incubation grew an
unusual Gram-negative bacillus,
which was later identified as Kingella kingae. He was treated with a
4-week course of cefotaxime, and
the findings of a cerebrospinal
fluid analysis after this time were
entirely normal. His plasma viscosity, C-reactive protein levels, and

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1774

rheumatoid factor values all returned to normal. He continued to
improve, though he was left with a
mild expressive aphasia.
COMMENT
Global aphasia without hemiparesis has been described and is usually the result of cardioembolism.1

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Figure 2. A transesophageal echocardiogram revealing the typical appearance of the aortic valve with
clearly visible vegetation (arrow).

It seems likely that this patient had
2 embolic events: the initial embolus resulting in the “odd behavior”described by his wife, possibly
representing a receptive aphasia;
and the second completing the
global aphasia. The magnetic resonance imaging scan correlates with
this, demonstrating infarctions in
the territories of both the anterior
and posterior divisions of the
middle cerebral artery (Figure 1).
Kingella kingae is a Gramnegative bacillus that is a member
of a fastidious group of organisms
called the HACEK group (Haemophilus species, Actinobacillus actinomycetemiomitans, Cardiobacterium hominis, Eikenella corrodens,
and Kingella species). These organisms are normal oropharyngeal
commensals and can take up to 3
weeks to culture. They are responsible for about 3% of cases of endocarditis,2 though K kingae endocarditis is rare, and this is the first
report of it causing cerebral in farction in an adult.
M. B. Lewis MB BS, MRCP
Leeds General Infirmary
Great George Street
Leeds LS1 3EX, England
(e-mail: m-k-lewis@email.msn.com)
J. M. Bamford MD, FRCP
Leeds
REFERENCES
1. Hanlon RE, Lux WE, Dromerick AW. Global aphasia without hemiparesis: language profiles and lesion distribution. J Neurol Neurosurg Psychiatry. 1999;66:365-369.
2. Berbari EF, Cockerill FR III, Steckelberg JM. Infective endocarditis due to unusual or fastidious microorganism. Mayo Clin Proc. 1997;72:532542.

Figure 3. A transesophageal echocardiogram showing vegetation attached to the mitral valve (arrow).

(REPRINTED) ARCH NEUROL / VOL 57, DEC 2000
1775

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