To the Editors: A new ventricular septal defect (VSD) occluder (Nit-Occlud Lê VSD, PFM Medical AG, Cologne, Germany) is currently considered investigational.1 So far, 102 patients have been treated in an ongoing multicenter study. No infectious complications have been reported. We report on a 4-year-old child with perimembranous VSD. A minimal left-to-right shunt remained after the procedure. He developed Kingella kingae endocarditis 4 months after the procedure. One week before his current admission, he developed a self-limited fever and diarrhea. He was hospitalized with malaise. The physical examination and signs were unremarkable. Transthoracic echocardiography demonstrated a small left-to-right residual shunt across the membranous VSD adjacent to the coil. Laboratory tests showed a white blood cell count of 12,400/mm3, with 56% polymorphonuclear cells, 8% band forms, 28% lymphocytes, hemoglobin level of 7.2g/dL, and platelet count of 149,000/mm3. Two days later, high fever with chills developed. Repeat TTE demonstrated large unstable vegetation (13 × 19 mm, Fig. 1), extending from the right ventricular aspect of the coil and floating in the right ventricular outflow tract. There was no valvular involvement or cardiac compromise. Three sets of blood cultures were taken, and empiric antibiotic therapy consisting of vancomycin, gentamicin, and ceftriaxone was initiated. K. kingae was isolated from all 3 blood cultures performed during the first 48 hours of treatment. Blood cultures performed later were sterile. Isolates were susceptible to ampicillin and ceftriaxone. Treatment with ceftriaxone was continued. Fever and chills resolved within 48 hours after initiating antibiotic therapy.Figure 1: Bidimensional echocardiography illustrating the coil located in the membranous area connected to large vegetation floating in the right ventricular outflow tract. C indicates coil; LV, left ventricle; RV, right ventricle; IVS, interventricular septum; V, vegetation: 13 × 19 mm; PV, pulmonary valve.Because of the existence of the very large unstable vegetation and the risk for disruption and pulmonary embolization of that large vegetation, the patient was taken to the operating room 5 days after initiation of antibiotic therapy. The coil and the vegetation were removed, and the VSD was closed by a pericardial patch. Samples taken at surgery from the site of the VSD closure, including the vegetation and the VSD occluder, were sterile. Pathologic samples showed an acute inflammatory infiltrate with polymorphonuclear cells, but no bacteria were demonstrated. After 6 weeks of parenteral antibiotic therapy, the postoperative course was uneventful with complete recovery. K. kingae endocarditis has been rarely described in children. More than half the cases were associated with congenital heart disease. In a recent nationwide study from Israel, endocarditis was reported in 8/322 (2.5%) episodes of bacteremia caused by K. kingae.2 Device-associated endocarditis in children is rare.3 Intracardiac foreign body may pose an increased risk for thrombus formation and endocarditis. Only a few cases of device-associated endocarditis have been reported, including one case of Kingella endocarditis reported after the use of an Amplatzer device.4 A third-generation cephalosporin should be included in the initial regimen of endocarditis.5 In our patient, endocarditis developed 4 months after the procedure, and it seemed not to be directly related to the procedure but rather to the development of bacteremia during a transient illness with a pathogen with high affinity to cause endocarditis. Awareness for the potential of Kingella endocarditis in this situation is warranted. Imad Kassis, MD Yael Shachor-Meyouhas, MD Pediatric Infectious Diseases Unit Meyer Children's Hospital Rambam Health Care Campus Haifa, Israel B. Rappaport Faculty of Medicine Technion-Israel Institute of Technology Ihab Khatib, MD Asad Khoury, MD Pediatric Cardiology Unit Meyer Children's Hospital Rambam Health Care Campus Haifa, Israel B. Rappaport Faculty of Medicine Technion-Israel Institute of Technology Trong Phi Le, MD Heart Center University of Hamburg Hamburg, Germany Avraham Lorber, MD Pediatric Cardiology Unit Meyer Children's Hospital Rambam Health Care Campus Haifa, Israel B. Rappaport Faculty of Medicine Technion-Israel Institute of Technology Haifa, Israel