Unilateral Gonococcal Ophthalmia Without Genital Infection: an Unusual Presentation in an Adult

Summary: We present the case of unilateral gonococcal ophthalmia without concomitant genital infection seen in an adult, with the potential for visual impairment if not adequately recognized and promptly treated.

Keywords: neisseria, gonococcal, ophthalmia, unilateral, visual impairment

Case history

A 43-year-old single, Asian male patient, resident in the UK for the last 25 years, presented to his general practitioner with left unilateral conjunctivitis. He was prescribed topical 1% chloramphenicol ointment to use with an oral analgesic. His left eye became increasingly painful, with impaired vision, and he was taken by ambulance 10 days later to the accident & emergency department. He was seen, and admitted to the ophthalmology ward. He had been unable to open his left eye for four days and the pain was unresponsive to paracetamol. Apart from right cataract surgery in 1997 and the use of reading glasses, there was no other significant medical history. His visual acuity was 6/6 in the right eye and 6/ 36 in the left eye. A muco-purulent discharge was noted in the left eye associated with conjunctival chemosis, marked eyelid swelling and a superficial keratopathy. Fundoscopy and measurement of intraocular pressure were not possible. A diagnosis of bacterial conjunctivitis was made. Appropriate swabs were inoculated into the blood-chocolate agar and MacConkey medium. The patient was started on oral flucloxacillin 250 mg six-hourly to cover the staphylococcal infection often associated with conjunctivitis and topical 0.3% ciprofloxacin and 0.5% chloramphenicol eye drops. The left eye was less painful 24 h later. He was discharged two days later with continuing improvement, and visual acuity was 6/6 in the right eye and 6/18 in the left eye. Bacteriological reports confirmed the light growth of Staphylococcus aureus and heavy growth of Neisseria gonorrhoeae. Both organisms were sensitive to gentamicin, ofloxacin, chloramphenicol, oxytetracycline and fusidic acid.

The patient was referred to the local genitourinary medicine department, and when he attended his left conjunctivitis (Figure 1) was still present. He declared himself heterosexual and stated that his last sexual contact had been two years ago in the UK. He had been treated for non-specific urethritis in 1990. He had recently relocated to our area from London and owned a hotel, and wondered if he could have been infected from the hotel bed linen. Genital examination was unremarkable and Gram stain of urethral materials only showed epithelial cells and mixed organisms.

The patient’s first and second void two-glass-urine tests were clear. Culture of urethral materials plated on commercial modified New York City medium and commercial non-selective Columbia agar were negative after incubation at 370C in an atmosphere of humidified 5% CO2 for 48 h. The urethral sample examined for Chlamydia trachomatis by enzyme-linked immunosorbent assay and confirmed with blocking assay to verify the presence of chlamydia antigen (IDEIA(TM) PCE, Dako, Cambridgeshire, UK) was negative.

Figure 1 Pre-treatment. (This figure can be seen in colour online)

Figure 2 Post-treatment with systemic antibiotics. (This figure can be seen in colour online.)

Syphilis antibodies tested by enzyme immunoabsorbent assay and hepatitis B surface antigen were negative. The patient was given another course of ofloxacin 400 mg twice a day for one week and advised to continue using topical chloramphenicol eye drops.

He returned three weeks later for follow-up and his left eye was now normal (Figure 2). The test of cure performed from the eye showed satisfactory resolution of his infection and he was discharged.

Discussion

The statutory reports from genitourinary medicine clinics in the UK do not have a specific category for adult gonococcal ophthalmia, which is currently coded as gonococcal complications; thus, the true incidence of gonococcal ophthalmia in adults in the UK is not known. This is a serious ophthalmological condition with the risk of visual impairment if not recognized and treated promptly. Clinicians providing care either as general practitioners, genitourinary medicine physicians or ophthalmologists need to be aware of it. There has been a recent report1 of concomitant ano-genital gonorrhoea and unilateral gonococcal ophthalmia seen in a young homosexual in Chester. It is, however, rare to see unilateral gonococcal ophthalmia in an adult without concomitant genital infection, and we are not aware of a similar report in the UK in recent years.

Gonococcal ophthalmia without concomitant genital gonorrhoeal infection in adults has been reported in the literature.2-5 In the report of an outbreak of 447 cases of gonococcal conjunctivitis in western and central Australia, Mak et al2 applied a genotyping method to DNA extracted from patient samples to characterize the gonococcus causing the epidemic and compared it with contemporaneous genital isolates. They found that all of the positive conjunctival specimens from western and central Australia that could be genotyped were indistinguishable, and were distinctly different from the genital gonococci, even when they shared the same auxotype and serotype. This suggested that the outbreak was due to a single genotype of N. gonorrhoeae that had probably been carried between communities by infected individuals.

Mak et al. did not find evidence to support the existence of a genital reservoir of the types causing epidemic gonococcal conjunctivitis, giving credence to the concept of non-sexually acquired gonococcal ophthalmia.

Other causes for adult non-sexually acquired gonococcal conjunctivitis reported in a large outbreak in North Omo, Ethiopia in over 9000 cases seen between 1987 and 1988 included inadequate personal hygiene and children using dirty water to wash their faces.3 A folk remedy – the practice of washing the eyes with urine to treat conjunctivitis4 – has also been reported, including iatrogenic inoculation.5 In children, particular attention should be directed to sensitively but firmly ensuring the screening of carer(s) to exclude sexual abuse.

Gonococcal conjunctivitis is an ophthalmic emergency and carries the risk of severe ulcerative keratitis, which may ultimately result in lightperception visual acuity impairment often requiring keratoplasty. Careful ophthalmological and microbiological monitoring is recommended to prevent possible complications, including blindness.

References

1 Price LM, O’Mahony C. Gonococcal ophthalmia treated with ciprofloxacin. Int J STD AIDS 2001;12:829-30

2 Mak DB, Smith DW, Harriett GB, Plant AJ. A large outbreak of conjunctivitis caused by a single genotype of Neisserin gonarrhoene distinct from those causing genital tract infections. Epidemiol Infect 2001;126:373-8

3 Mikru FS, Molla T, Ersumo MJ, et al. Community-wide outbreak of Neisseria gonorrhoeae conjunctivitis in Konso district, North Omo administrative region. Ethiop Med J 1991;29:27-35

4 Alfonso E, Friedland B, Hupp S, et al. Neisserin gonorrhoeae conjunctivitis. An outbreak during an epidemic of acute hemorrhagic conjunctivitis. JAMA 1983;250:794-5

5 Malhotra R, Karim QN, Acheson JF. Hospital-acquired adult gonococcal conjunctivitis. J Infect 1998;37:305

(Accepted 1 March 2004)

Tubonye C Harry MRCOG1 and Peter D Black FRCS FRCOphth2

1 Bure Clinic, Department of Genitourinary Medicine, Great Yarmouth, Norfolk NR31 6LA; 2 James Paget Healthcare NHS Trust, Great Yarmouth, Norfolk, UK

Correspondence to: Dr Tubonye C Harry

Email: tcharry@bureclinic.com

Copyright Royal Society of Medicine Press Ltd. Jan 2005