Accepted Manuscript

Gonococcal Conjunctivitis: A Case Report of an Unusual Mode of Transmission

Anna Jo Bodurtha Smith, MD, MPH, MSc, Samuel B. Holzman, MD, Reza Sedighi
Manesh, MD, Trish M. Perl, MD, MSc

PII: S1083-3188(16)30273-X
DOI: 10.1016/j.jpag.2016.11.003
Reference: PEDADO 2065

To appear in: Journal of Pediatric and Adolescent Gynecology

Received Date: 27 April 2016

Revised Date: 23 August 2016
Accepted Date: 9 November 2016

Please cite this article as: Bodurtha Smith AJ, Holzman SB, Sedighi Manesh R, Perl TM, Gonococcal
Conjunctivitis: A Case Report of an Unusual Mode of Transmission, Journal of Pediatric and Adolescent
Gynecology (2016), doi: 10.1016/j.jpag.2016.11.003.

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 ACCEPTED MANUSCRIPT

Title: Gonococcal Conjunctivitis: A Case Report of an Unusual Mode of Transmission

Authors:
Anna Jo Bodurtha Smith, MD, MPH, MSc1
Samuel B. Holzman, MD2
Reza Sedighi Manesh, MD3
Trish M. Perl, MD, MSc2,4

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Author Affiliations:
1
Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine,

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Baltimore, MD
2
Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of
Medicine, Baltimore, MD

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Department of Medicine, Division of Hospital Medicine, Johns Hopkins University School of
Medicine, Baltimore, MD
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Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore,
MD

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Corresponding Author: Anna Jo Bodurtha Smith, MD, MPH, Department of Gynecology and
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Obstetrics, Phipps, 600 North Wolfe Street, Johns Hopkins University School of Medicine,
Baltimore, MD,

Word Count: 886

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Keywords: Adolescent, female, gonorrhea, oral sex, conjunctivitis, sexually transmitted

infection
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Financial Disclosure: The authors have no financial relationships relevant to this article to
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disclose.

Funding Source: The authors received no support for this project.

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Potential Conflicts of Interest: The authors have no conflicts of interest relevant to this article
to disclose.
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Abstract (Word Count 123/125)

Background: Outside of the newborn period, development of gonococcal conjunctivitis is rare
and predominantly occurs through auto-inoculation. We report an unusual case of gonococcal
conjunctivitis in a young woman exposed through direct inoculation.

Case: A 19-year-old woman presented with purulent ocular discharge, severe pain, and
decreased vision unresponsive to topical antibiotics or ganciclovir approximately 3 weeks after

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accidental ocular exposure to seminal fluid during unprotected oral sex. Cultured ocular drainage
grew Neisseria gonorrhea; vaginal and throat cultures were negative. She was successfully
treated with ceftriaxone and doxycycline for 10 days.

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Summary and Conclusion: Clinicians should be aware of the potential for vision-threatening
gonococcal conjunctivitis from exposure during sexual contact.

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Introduction

Conjunctivitis caused by Neisseria gonorrhea has been considered rare except in newborns.

However, the incidence in adults may be increasing, given the increased frequency of urogenital

gonococcal infections in the United States.1–3 In Ireland, cases of conjunctivitis secondary to

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sexually-transmitted infections (STI’s) recently doubled in correlation with a rise in urogenital

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infections.1 Although adult cases of gonococcal conjunctivitis have largely been attributed to

auto-inoculation in men with asymptomatic urogenital gonorrhea, changing sexual practices

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could lead to increased occurrence in young women.4 In recent national surveys, two-thirds of

adolescents reported having had oral sex, and the majority perform this activity without condom

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usage.3–5 We present an unusual case of Neisseria gonorrhea conjunctivitis acquired during oral
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sex.
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Case
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A 19-year-old woman with no significant past medical history presented to an ophthalmology

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clinic with 3 weeks of persistent ocular discharge, redness, and moderate right eye pain. She

denied fever, chills, sore throat, arthralgia, abdominal pain, vaginal discharge, or dysuria. No
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sexual history was obtained. She was treated with topical tobramycin-dexamethasone and

ganciclovir for presumed viral conjunctivitis.

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The next day, she re-presented to the clinic with increased ocular discharge and severe
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pain. On physical exam, she was afebrile with normal vital signs. The right eye was swollen shut

with significant purulent discharge, and vision in it decreased from 20/20 to 20/60. She was

admitted for treatment of presumed bacterial cellulitis.

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On admission, her white blood cell count was 13,500/mm3 with a C-reactive protein of

6.2 milligrams per deciliter (reference range, 0-1 mm/dL) and erythrocyte sedimentation rate of

52 millimeters per hour (reference range, 0-29 mm/hr). A computed tomography scan

demonstrated right peri-orbital cellulitis, and culture of the discharge was collected. She was

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started on intravenous vancomycin and cefepime as well as moxifloxacin eye drops. Despite two

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days of antibiotics, her right eye remained swollen and red with purulent discharge, but vision

was stable at 20/60.

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On the third hospital day, the culture of the eye drained grew N. gonorrhea susceptible to

ceftriaxone, ciprofloxacin, and spectinomycin, intermediate to penicillin and resistant to

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tetracycline. The Infectious Diseases service was consulted. Further history revealed accidental
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ocular exposure to seminal fluid during oral sex with a new partner three weeks prior to

presentation. She denied previous sexually-transmitted infections and used condoms

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inconsistently during vaginal and oral sex with her current and prior male partners. Urine
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gonorrhea and chlamydia tests were negative, indicating that direct inoculation during oral sex
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was likely the source of infection. Pregnancy and HIV tests were negative.

Given the severity of vision changes and delay in treatment, the Infectious Disease
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service advised treatment with ceftriaxone 2 grams initially intravenously and then

intramuscularly for a ten day course. She received doxycycline 100 milligrams orally once a day
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for ten days for dual coverage (i.e., empirical treatment of C. trachomatis) and continued
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moxifloxacin eye drops. After two days of ceftriaxone-doxycycline, the eye swelling and

discharge decreased, and the peripheral white blood cell count had decreased to 4,800/mm3. The

vision in her right eye had returned to 20/20 after one week of treatment. She completed ten days

of antibiotics with complete resolution of symptoms.

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Discussion

We present a young woman with symptoms of conjunctivitis where a sexual history was

not initially obtained, yet would have suggested the possibility of an unusual cause of

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conjunctivitis, such as Neisseria gonorrhea. Obtaining complete sexual history is critical as

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delays in treatment of gonococcal conjunctivitis can cause corneal perforation and permanent

vision loss.6 As seen in this case, hyper-purulent discharge is the hallmark of gonococcal

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conjunctivitis, and gram stain and culture are diagnostic over 90% of the time.3,7 The Centers for

Disease Control and Prevention (CDC) recommends dual therapy for gonococcal conjunctivitis

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with 1 gram ceftriaxone intramuscular and 100 mg doxycycline or 1 gram azithromycin for
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possible chlamydia, even if C. trachomatis testing is negative as in this case While the CDC

currently recommends only a single dose of ceftriaxone for gonorrhea, alongside C. trachomatis
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coverage, this regimen is based on a 1989 case series in which patients presented early to care,
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and we elected for longer therapy, given the delayed diagnosis and severity of ocular
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complications.8 Topical steroids and/or corneal surgery may also be used if corneal injury

persists or progresses despite antibiotics.9,10

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Clinicians should consider gonococcal conjunctivitis in sexually-active adolescents with

ocular symptoms and in adolescents presenting with urogenital STI. While the vast majority of
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conjunctival exposures become symptomatic, the incubation period from N. gonorrhea exposure
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to ocular symptoms varies from three to 19 days compared to two to seven days for urogenital

gonorrhea. Adolescents engaged in oral sex with ocular exposure to body fluids may not yet be

symptomatic at time of urogenital treatment.6 Moreover, gonococcal conjunctivitis can occur

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after successful treatment of urogenital infection, given that higher antibiotic doses are needed to

achieve optimal concentrations in the eye.10

Conclusion

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We describe an unusual case of conjunctivitis caused by N. gonorrhea that resulted from a direct

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ocular exposure during oral sex. The initial diagnosis was missed because a sexual history was

not obtained early in the patient’s care. Clinicians should be aware that gonococcal conjunctivitis

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is not just a neonatal disease. With increasing prevalence of alternate forms of sexual contact and

low condom usage, clinicians should have a low threshold for testing women with symptoms and

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sexual history suggestive of gonococcal conjunctivitis.
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