A sexually active 37-year-old man presented with 1 week of rapidly worsening eye pain unimproved with antibiotic drops. Exam revealed bilateral copious mucopurulent discharge that reappeared within minutes of wiping (Fig. 1), lid edema, conjunctival chemosis, complete right corneal “melting,” and left full-thickness perforating ulcerations. Parenteral ceftriaxone and every hour moxifloxacin drops were started and he emergently underwent bilateral ophthalmologic salvage surgery. Intracellular gram-negative diplococci on gram stain grew Neisseria gonorrhoeae (Fig. 2). Though otherwise asymptomatic, a urethral sample was positive for gonococcal urethritis. After weeks of therapy, including full-thickness corneal transplant, vision was 20/30 in the left eye and light perception only in the right.
Adult gonococcal conjunctivitis, while infrequent, is important to recognize because, unlike more common forms of bacterial conjunctivitis, gonococcus can cause corneal perforation (effectively an open globe) requiring surgical repair. Left untreated, corneal destruction can lead to blindness within hours.1 Copious hyperpurulent discharge (described as “fountain of pus”2) that reappears quickly after wiping away is highly suggestive and warrants immediate parenteral and topical antibiotics, microbiologic evaluation, ophthalmologic consultation, and hospitalization.1,2,3 Testing for HIV and sexually transmitted diseases is warranted as concomitant urethritis is common.1 Recognized and treated prior to corneal damage, outcomes are favorable.2, 4
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The authors gratefully acknowledge assistance regarding technical assistance (Nicholas Mark, MD), pre-hospital care information (Michael R. Cozzetta, OD), microbiology images (Nancy Madinger, MD, Bruce McCallister, MD, Jeffrey Schowinsky, MD), and manuscript suggestions (Reza Manesh, MD, Lauren Taney, MD).
Patient provided written consent to use of his story and images including photos of face for publication for the purposes of education.
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Lessing, J.N., Slingsby, T.J. & Betz, M. Hyperacute Gonococcal Keratoconjunctivitis. J GEN INTERN MED 34, 477–478 (2019). https://doi.org/10.1007/s11606-018-4825-8