http://std.sagepub.com/International Journal of STD & AIDS

http://std.sagepub.com/content/16/1/78The online version of this article can be found at:

 DOI: 10.1258/0956462052932773

2005 16: 78Int J STD AIDSTubonye C Harry and Peter D Black

Unilateral gonococcal ophthalmia without genital infection: an unusual presentation in an adult  

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- Jan 1, 2005Version of Record >>

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CASE REPORT

Unilateral gonococcal ophthalmia without genitalinfection: an unusual presentation in an adult

Tubonye C Harry MRCOG1 and Peter D Black FRCS FRCOphth2

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

Summary: We present the case of unilateral gonococcal ophthalmia withoutconcomitant genital infection seen in an adult, with the potential for visualimpairment if not adequately recognized and promptly treated.

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

Case history

A 43-year-old single, Asian male patient, residentin the UK for the last 25 years, presented to hisgeneral practitioner with left unilateral conjuncti-vitis. He was prescribed topical 1% chlorampheni-col ointment to use with an oral analgesic. His lefteye became increasingly painful, with impairedvision, and he was taken by ambulance 10 dayslater to the accident & emergency department. Hewas seen and admitted to the ophthalmology ward.He had been unable to open his left eye for fourdays and the pain was unresponsive to paraceta-mol. Apart from right cataract surgery in 1997 andthe use of reading glasses, there was no othersignificant medical history. His visual acuity was6/6 in the right eye and 6/36 in the left eye. Amuco-purulent discharge was noted in the left eyeassociated with conjunctival chemosis, markedeyelid swelling and a superficial keratopathy.Fundoscopy and measurement of intraocular pres-sure were not possible. A diagnosis of bacterialconjunctivitis was made. Appropriate swabs wereinoculated into the blood-chocolate agar andMacConkey medium. The patient was started onoral flucloxacillin 250mg six-hourly to cover thestaphylococcal infection often associated with con-junctivitis and topical 0.3% ciprofloxacin and 0.5%chloramphenicol eye drops. The left eye was lesspainful 24 h later. He was discharged two days laterwith continuing improvement, and visual acuitywas 6/6 in the right eye and 6/18 in the left eye.Bacteriological reports confirmed the light growthof Staphylococcus aureus and heavy growth ofNeisseria gonorrhoeae. Both organisms were sensitiveto gentamicin, ofloxacin, chloramphenicol, oxyte-tracycline and fusidic acid.

The patient was referred to the local genitour-inary medicine department, and when he attendedhis left conjunctivitis (Figure 1) was still present.He declared himself heterosexual and stated thathis last sexual contact had been two years ago inthe UK. He had been treated for non-specificurethritis in 1990. He had recently relocated toour area from London and owned a hotel, andwondered if he could have been infected from thehotel bed linen. Genital examination was unre-markable and Gram stain of urethral materials onlyshowed epithelial cells and mixed organisms.

The patient’s first and second void two-glass-urine tests were clear. Culture of urethral materialsplated on commercial modified New York Citymedium and commercial non-selective Columbiaagar were negative after incubation at 371C in anatmosphere of humidified 5% CO2 for 48 h. Theurethral sample examined for Chlamydia trachomatisby enzyme-linked immunosorbent assay and con-firmed with blocking assay to verify the presence ofchlamydia antigen (IDEIAt PCE, Dako, Cambrid-geshire, UK) was negative.

International Journal of STD & AIDS 2005; 16: 78–79

78

Figure 1 Pre-treatment. (This figure can be seen in colour online)Correspondence to: Dr Tubonye C HarryEmail: tcharry@bureclinic.com

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Syphilis antibodies tested by enzyme immuno-absorbent assay and hepatitis B surface antigenwere negative. The patient was given anothercourse of ofloxacin 400mg twice a day for oneweek and advised to continue using topicalchloramphenicol eye drops.

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

Discussion

The statutory reports from genitourinary medicineclinics in the UK do not have a specific category foradult gonococcal ophthalmia, which is currentlycoded as gonococcal complications; thus, the trueincidence of gonococcal ophthalmia in adults in theUK is not known. This is a serious ophthalmolo-gical condition with the risk of visual impairment ifnot recognized and treated promptly. Cliniciansproviding care either as general practitioners,genitourinary medicine physicians or ophthalmol-ogists need to be aware of it. There has been arecent report1 of concomitant ano-genital gonor-rhoea and unilateral gonococcal ophthalmia seen ina young homosexual in Chester. It is, however, rareto see unilateral gonococcal ophthalmia in an adultwithout concomitant genital infection, and we arenot aware of a similar report in the UK in recentyears.

Gonococcal ophthalmia without concomitantgenital gonorrhoeal infection in adults has beenreported in the literature.2–5 In the report of anoutbreak of 447 cases of gonococcal conjunctivitisin western and central Australia, Mak et al.2

applied a genotyping method to DNA extractedfrom patient samples to characterize the gonococcus

causing the epidemic and compared it withcontemporaneous genital isolates. They found thatall of the positive conjunctival specimens fromwestern and central Australia that could begenotyped were indistinguishable, and were dis-tinctly different from the genital gonococci, evenwhen they shared the same auxotype and serotype.This suggested that the outbreak was due to asingle genotype of N. gonorrhoeae that had probablybeen carried between communities by infectedindividuals.

Mak et al. did not find evidence to support theexistence of a genital reservoir of the types causingepidemic gonococcal conjunctivitis, giving cre-dence to the concept of non-sexually acquiredgonococcal ophthalmia.

Other causes for adult non-sexually acquiredgonococcal conjunctivitis reported in a large out-break in North Omo, Ethiopia in over 9000 casesseen between 1987 and 1988 included inadequatepersonal hygiene and children using dirty water towash their faces.3 A folk remedy – the practice ofwashing the eyes with urine to treat conjunctivitis4

– has also been reported, including iatrogenicinoculation.5 In children, particular attentionshould be directed to sensitively but firmly ensur-ing the screening of carer(s) to exclude sexual abuse.

Gonococcal conjunctivitis is an ophthalmic emer-gency and carries the risk of severe ulcerativekeratitis, which may ultimately result in light-perception visual acuity impairment often requir-ing keratoplasty. Careful ophthalmological andmicrobiological monitoring is recommended toprevent possible complications, including blind-ness.

References

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

2 Mak DB, Smith DW, Harnett GB, Plant AJ. A large outbreakof conjunctivitis caused by a single genotype of Neisseriagonorrhoeae distinct from those causing genital tract infec-tions. Epidemiol Infect 2001;126:373–8

3 Mikru FS, Molla T, Ersumo MJ, et al. Community-wideoutbreak of Neisseria gonorrhoeae conjunctivitis in Konsodistrict, North Omo administrative region. Ethiop Med J1991;29:27–35

4 Alfonso E, Friedland B, Hupp S, et al. Neisseria gonorrhoeaeconjunctivitis. An outbreak during an epidemic of acutehemorrhagic conjunctivitis. JAMA 1983;250:794–5

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

(Accepted 1 March 2004)

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

Harry and Black. Gonococcal ophthalmia without genital infection 79

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