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CASE REPORTING

By JI Pati, Poquiz
Department of Ophthalmology
Ospital ng Maynila Medical Center
July 14 , 2016

THE CASE

Name of patient: EC
Date of history : July 5, 2016
Informant : Patient, 41/M
Reliability : 90%

This is a case of E.C., a 41


year old Male who came in due
to bilateral eye redness and
eye discharge

Chief complaint:
bilateral eye redness and eye
discharge

HISTORY OF PRESENT
ILLNESS
Patient noted
sudden onset of
eye redness
and pain, left
eye
No discharge,
matting,
lacrimation,
pruritus

6 days PTC

Increased
severity of
redness, left eye
+ Matting, left
eye
+Copious
yellow green
discharge, left
eye
No lacrimation,
pruritus

5 days PTC

Persistence of
symptoms
+ Redness, pain,
matting,
copious yellow
green
discharge, right
eye

Persistence of
symptoms

Px washed both
eyes with tap
water no relief

4 days PTC

CONSULT

No history of exposure to
chemical/irritants
No symptom of severe itching
symptom

Past medical history

(+) BA, last attack 9 yrs ago


(-) HPN
(-) DM
(-) Allergies to food or medications
No history of allergic rhinitis, atopic dermatitis
(-) PTB
(+) Penile discharge (consulted at Kabaka Clinic, Feb, 2016)
completed treatment with Doxycycline 100mg/tab BID x 7
days

Surgical
(+) s/p Surgery secondary to head trauma (PGH, March
2016)

FAMILY HISTORY
(+) HPN, Maternal
(+) DM, paternal
(+) BA, paternal

PSHX
3 sexual partners (1 sexual partner
at present)
Last coitus 1day PTC
Smoker (2 sticks per day, since HS)
Occasional alcohol beverage drinker
Substance abuse x 5 yrs (Marijuana,
last intake 2010)
Occupation : Tricycle driver

REVIEW OF SYSTEMS
GENERAL
INTEGUMENT

(-) fever (-) chills (-) fatigue (-) headache


(-) pruritus (-) erythema

HEENT

(-) hair loss (-) ear ache (-) ear discharge (-)
epistaxis (-) hoarseness

NECK
RESPIRATORY
CARDIOVASCULA
R
GASTROINTESTIN
AL
GENITAL
URINARY
HEMATOLOGIC
MUSCULOSKELET
AL
NEUROLOGIC

(-) stiff neck


(-) difficulty of breathing (-) cough (-)
wheezing
(-) chest pain (-) palpitations (-) orthopnea (-)
PND
(-) nausea, (-) vomiting, (-) diarrhea, (-)
hematemesis, (-) abdominal pain
(-) pain, (-) discharge
(-) polyuria, (-) hematuria, (-) oliguria, (-)
urgency
(-) pallor, (-) easy bruising
(-) joint swelling, (-) stiffness, (-) rigidity
(-) convulsion, (-) seizure

PHYSICAL EXAM

Visual acuity
OD: 20/200 +1, NIPH
OS: 20 /80, NIPH

External eye exam


PERTL 3mm constricting to 2mm

(+) Matting
Hyperemic
Palpebral/
bulbar
conjunctiva

(+) Matting
Hyperemic
Palpebral/
bulbar
conjunctiva

Hyperemic sclera
(+) Yellowish/ greenish
(+) Yellowish/ greenish
mucopurulent eye
mucopurulent eye
discharge
discharge
Symmetrical eyes with fine and aligned eyebrows.
Intact visual fields
(+) ROR

Other eye findings:

(+) papillary reaction


(+) eyelid edema
(-) chemosis
(-) follicles
(-) chemosis
(-) conjunctival hemmorhage
(-) inflammatory membranes (tarsal)
(-) peripheral corneal epithelial ulcers and
stromal infiltrates
(-) collarettes

Extraocular muscles

Slit lamp examination

1x
1x
(+)

4x

SPKs

1x
1x
(+)

4x

SPKs

Normocephalic, symmetrical
No lesions, scaling, masses
Symmetrical ears with normoset
pinna
Pink and non swollen nasal mucosa
and turbinates
Symmetically aligned nasal septum
Midline tongue, uvula
No exudates in pharynx
No Preauricular and cervical
lymphadenopathy
Symmetric chest expansion, no
retractions, clear breath sounds
Adynamic precordium, normal rate,
regular rhythm, no murmur
Flat, soft, non-tender, normoactive
bowel sounds

HEENT

Chest and
Lungs
Heart
Abdomen

SALIENT FEATURES

Salient features
41/M
Cc: Yellow green discharge,OU
PMH: Penile discharge and STD
Sexual history: 3 sexual partners
Hyperemic sclera and palpebral
conjunctiva
Yellow green discharge, OU
SPKs, OU

Pertinent Positive: PE

Acute
Mild eye pain
Diffuse hyperemia
(+) mucopurulent discharge
(+) tearing
Eye redness
Matting
(+) papillary reaction
SPKs, OU

Pertinent Negative
History
No allergies to food & drug
No history of allergic rhinitis, atopic dermatitis, BA
No history of exposure to chemical/irritants
No severe itching symptom
No history of pharyngitis
PE
No preauricular adenopathy
(-) tarsal conjunctival scarring (Art line)
(-) follicles
(-) eyelid edema
(-) chemosis
(-) conjunctival hemmorhage
(-) inflammatory membranes (tarsal)
(-) peripheral corneal epithelial ulcers and stromal infiltrates
(-) eyelid nodules, lesions, masses
(-) collarettes

APPROACH TO DIAGNOSIS

Eye Discharge
Infectious

Non- Infectious
Allergic Conjunctivitis
Chemical/Irritative
Conjunctivitis

Parasitic (rare)
Fungal
Acanthamoe
(rare)
bic
Candidal
Ascariasis
Conjunctiviti
Cysticercusis s
Taeniasis

Viral
Conjunctivitis
Adenoviral
Conjunctivitis
Primary Herpes
Simplex Infection

Bacterial Conjunctivitis
Chlamydial Conjunctivitis
Gonococcal Conjunctivitis
Streptococcal Conjunctivitis
Haemophilus influenza
Conjunctivitis
Staphylococcal
Conjunctivitis

DIFFERENTIAL DIAGNOSIS
Viral Conjunctivitis
Adenoviral Conjunctivitis
Primary Herpes Simplex
Conjunctivitis
Bacterial Conjunctivitis
Chlamydial Conjunctivitis
Gonococcal Conjunctivitis
Streptococcal Conjunctivitis
Haemophilus influenza
Conjunctivitis
Staphylococcal Conjunctivitis
Allergic Conjunctivitis

DIFFERENTIAL DIAGNOSIS

Allergic Conjunctivitis

RULE OUT

RULE IN

Acute
Mild pain
Diffuse hyperemia
(+) discharge (exudate)
(+) moderate tearing
No preauricular adenopathy
(+) Hx of BA

(+) mucopurulent discharge


[serous/mucoid in allergic
conjunctivitis)
No allergies to food & drug
No history of allergic rhinitis,
atopic dermatitis
No history of exposure to
chemical/irritants
No severe itching symptom

Viral Conjunctivitis

RULE OUT

RULE IN

Acute
Mild pain
Diffuse hyperemia
(+) discharge
(+) tearing

(+) mucopurulent discharge


[serous in viral conjunctivitis)
(+) Papillary reaction (not present
in viral)
(-) follicles (present in all cases)
pseudomembrane (HSV)
No severe itching symptom
No preauricular adenopathy
(common in viral conjunctivitis)

Chlamydial Conjunctivitis

RULE OUT

RULE IN

Sexually active
(+) Hx of Penile Discharge
Acute in presentation
Mild pain
Diffuse hyperemia
(+) mucopurulent discharge
(+) tearing

(-) follicles (present in all


cases of chlamydia, herbert)
(-) tarsal conjunctival scarring
(Art line)
No preauricular adenopathy
(common in inclusion
chlamydial conjunctivitis)

Bacterial Conjunctivitis

RULE IN

Acute in presentation
Mild pain
Diffuse hyperemia
(+) mucopurulent discharge
( (+) tearing
(+) eye redness

RULE OUT

DIFFERENTIAL DIAGNOSIS
Bacterial Conjunctivitis
Chlamydial Conjunctivitis
Streptococcal Conjunctivitis
Haemophilus influenza
Conjunctivitis
Staphylococcal Conjunctivitis
Gonococcal Conjunctivitis

Streptococcal Conjunctivitis
RULE IN

Mild pain
Diffuse hyperemia
(+) mucopurulent
discharge
(+) papillary reaction

RULE OUT
No history of cough
and colds ;
pharyngitis
(-) eyelid edema
(-) chemosis
(-) conjunctival
hemorrhage
(-) inflammatory
membranes (tarsal)

H. influenza Conjunctivitis
RULE IN

Mild pain
Diffuse hyperemia
(+) mucopurulent
discharge
(+) eyelid edema

RULE OUT
(-) cough and colds

Staphylococcal Conjunctivitis
RULE IN

Acute in presentation
Eye redness
Mild pain
Diffuse hyperemia
(+) mucopurulent
discharge

RULE OUT
(-) eyelid lesion
(blepharoconjunctivit
is)
(-) inflammatory
membrane (tarsal)
(-) collarettes

Cannot totally rule out

Gonococcal Conjunctivitis

RULE IN

Sexually active
Multiple sex partners (3)
Mild pain
Diffuse hyperemia
(+) mucopurulent discharge
SPKs, OU
(+) papillary reaction

RULE OUT

Gonoccocal
FINAL DIAGNOSISOU
Conjunctivitis,

DISCUSSION

Gonococcal
Conjunctivitis
Gonococcal conjunctivitis is a highly
contagious eye infection caused by
Neisseria gonorrheae

Other characteristics

Clinical Picture
Localised, fairly severe infection of
the conjunctiva
With intense inflammation and
copious purulent discharge
With or without periorbital edema
Corneal ulceration, perforation and
blindness can occur if treatment is not
given promptly

Mode of Transmission
I. Neonatal infection (gonococcal ophthalmia neonatorum) occurs
during passage of the infant through the birth canal if the mother is
infected with genital Neisseria gonorrheae
II. Sporadic cases occur in older children and adults where the source
is usually someone with a genital infection (autoinoculation)
a)

b)

A person who has genital gonorrhea who (usually) accidentally infects his or her
eyes by touching them with fingers or fomites (eg clothes, towels) contaminated
with their genital secretions
person becomes infected by contact with the contaminated fingers or fomites of
another person who has genital gonorrhea

III. Epidemics can arise from a person with gonococcal conjunctivitis


transmitting infection by direct, non-intimate interpersonal contact,
contact with infected fomites (eg clothes, towels) or by transmission
by flies

Incubation Period
Usually 2 to 7 days, but sometimes
can be longer

Period of Communicability
May extend for months in untreated
people
Infectivity ceases within hours of
appropriate antibiotic therapy.
Patients should be isolated /
excluded from school until 24 hours
after treatment

LABORATORY AND
DIAGNOSTICS

Pathology tests
All suspect patients should have 2
swabs taken, 1 for microscopy, culture
and sensitivity (MC&S) and 1 for PCR for
gonorrhoea and chlamydia
For MC&S: roll the swab on a slide and let
the slide air dry, place the swab
Modified Amies or Stuarts transport
medium (do not refrigerate)
For PCR place the swab in a dry tube and
put in the fridge.
(CDC guidelines,2010)

Culture

HISTOLOGY

Gram stain showing multiple gram negative diplococci


within PMLs (intracellular), smear from the eye

Case Definition
I. Confirmed case
Neisseria gonorrhoeae detected in a conjunctival specimen by:
Culture, OR
A nucleic acid technique (NAT) such as Polymerase Chain Reaction
(PCR)
where 2 different assays are both positive for the same specimen

II. Probable case


A clinically compatible illness and either:
Gram negative intracellular diplococci visible on microscopy of a
conjunctival specimen, OR
Epidemiologically linked to a laboratory confirmed case within 1 week
of a confirmed case and occurring either in the same household or same
schoolroom environment

.
(CDC guidelines,2010)

MANAGEMENT

CDC, 2010

For all suspected cases

Collect swabs ( GS/CS)


Irrigate the eyes with saline solution to
remove the discharge
Check visual acuity, and check cornea
for ulceration with fluorescein.
If the eyelids are too swollen to be able
to examine the eye, discuss with an
ophthalmologist and consider immediate
treatment and transfer to hospital
Antibiotic eye drops may be of some use
in addition to parenteral antibiotics if
there is corneal ulceration or staining

(CDC guidelines,2010)

Management of sporadic
cases in older children or
adults

NOTE: All persons with confirmed or likely


gonococcal conjunctivitis should have
either a low vaginal swab (either self
administered or by the clinician), or first
void urine test for MC&S and gonorrhoea
and chlamydia PCR.
Persons found to have genital infection
should have a full STI work up ( VDRL,
RPR, HIV screening) and management
as per standard practice.

(CDC guidelines,2010)

Management of sporadic
cases in older children or
adults

If there is no loss of visual acuity or


corneal staining, treat with:
Ceftriaxone 50mg/kg to a
maximum of 1g as a single IM or
IV dose
Exclude from school or child care for
24 hours after treatment.
(CDC guidelines,2010)

Other Antibiotics:
Eryhtromycin Eye ointment as lid scrub, OU
For gram positive coverage

Levofloxacin Eye solution, 1 gtt to OU Q1


For gram negative coverage

Doxycycline 100mg/tab TID x 10 days


blood borne bacteria/parasites (broad
coverage)

Azithromycin 1g SD
Chlamydial coverage

All members of the household, or members of


same classroom for a school age child,
should be examined for conjunctivitis
If signs are present, swabs should be taken
as for all suspected cases
Immediate treatment of household or school
room contacts even if they have no
symptoms may be necessary to prevent
complications in them or further
dissemination (CDC guidelines)

Management of Cases in
Neonates/Infants
For babies less than 2 weeks old, or with
severe conjunctivitis or with corneal
ulceration:
1. Do investigations and eye toilet as for all
suspected cases
2. Give 50mg/kg of IM ceftriaxone to a
maximum of 125mg immediately

* Neonatal Eye Prophylaxis: Erythromycin(0.5%)


ophthalmic ointment in each eye in a single
application

Management of an
Epidemic situation
All members of the household and
members of same classroom for a school
age child, should be treated regardless of
whether there are clinical signs of
conjunctivitis.
Treat both children and adults:
Procaine penicillin intramuscularly (IM)
as a single dose (50,000 units = 50
mg /kg (to a maximum of 1,500,000
units = 1.5g)

General measures
Encourage frequent washing of face and
hands with warm water and soap and
using clean towels
Provide information to all close
household contacts and family members
on the importance of good hygiene as a
way of preventing the spread of infection
Warn families to re-present if there is
persisting eye infection, fevers or other
symptoms such as arthritis.

THANK YOU!
JI Pati, Poquiz

Reference
World Health Organization. Guidelines for the management of
sexually
transmitted infections. 2003. Geneva, World Health
Organization.
CDC. Guidelines on Gonococcal Conjunctivitis. 2010
Vaughan and Asbury General Ophthalmology (17th edition)