A young man with red eye
BMJ 2022; 376 doi: https://doi.org/10.1136/bmj-2021-064287 (Published 09 March 2022) Cite this as: BMJ 2022;376:e064287
- 1Department of Medicine, National Cheng Kung University, Tainan, Taiwan
- 2Department of Ophthalmology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Correspondence to: Y-H Huang jackhyh{at}gmail.com
A man in his 30s had left eye redness for three days. He attended a local clinic where acute conjunctivitis was diagnosed, but symptoms did not improve after applying topical fluorometholone 0.1% and sulfamethoxazole 4% four times daily for two days to treat acute conjunctivitis. He attended the ophthalmology clinic for further treatment. His best corrected visual acuity in the right eye was 20/20; visual acuity in the left eye could not be measured because of severe pain and tenderness. On slit lamp examination (fig 1), there was left eye lid oedema, subepithelial infiltrates, conjunctival chemosis, and excessive mucopurulent discharge on the ocular surface. The patient also reported dysuria and a whitish urethral discharge for one week; and a new sexual contact three days before the onset of these urethral symptoms.
Slit lamp image of the left eye, showing subepithelial infiltrates, conjunctival chemosis (swelling and oedema), and mucopurulent discharge
Questions
1 What is the most likely diagnosis?
2 What are the differential diagnoses?
3 How would you treat this condition?
Answers
1 What is the most likely diagnosis?
Gonococcal conjunctivitis. Acute onset urethritis and conjunctivitis with large amounts of mucopurulent discharge are characteristic signs.12 Ulceration with subsequent corneal thinning and perforation can develop.13 Chemosis and eye tenderness are common.124 It occurs in neonates and in sexually active adults.12 A thorough social and sexual history helps with diagnosis.45 Early management can prevent devastating complications, such as blindness and meningitis.14
Gonococcal ocular infection generally occurs 3-19 days after urinary tract symptoms.67 The degree of corneal involvement varies, but common types can include marginal corneal melt and subepithelial or stromal infiltrates, or both.1 The incidence of gonococcal conjunctivitis in adults is increasing, especially with penicillinase-producing Neisseria gonorrhoeae.7
2 What are the differential diagnoses?
Eyelid oedema can mimic preseptal cellulitis.8 Epidemic keratoconjunctivitis might also be suspected when only a small amount of ocular discharge is present.3 Other differentials of urethral discharge with ophthalmic signs include reactive arthritis (formerly known as Reiter’s syndrome), and non-gonococcal urethritis with conjunctivitis.9 In reactive arthritis, inflammatory arthritis accompanies urethritis and mild, transient conjunctivitis (without excessive mucopurulent discharge).1011Chlamydia trachomatis, Mycoplasma genitalium, and adenovirus are causative agents of non-gonococcal urethritis with conjunctivitis.12 In non-gonococcal urethritis, conjunctivitis is usually chronic and without large amounts of mucopurulent discharge—conjunctivitis can develop over weeks or months and might be related to sexual activity or autoinoculation.13
Learning points
Consider gonococcal conjunctivitis when patients present with chemosis and excessive mucopurulent discharge, especially sexually active adults.
Early diagnosis can prevent blindness and meningitis.
Patient outcome
Gonococcal conjunctivitis was confirmed when Gram stain of conjunctival scrapings revealed gram negative cocci and aerobic culture from both conjunctiva and urethral discharge showed Neisseria gonorrhoeae. A polymerase chain reaction test is considered as the gold standard of diagnosing gonococcal conjunctivitis4; in this case, smear and culture helped doctors to diagnose quickly gonococcal infection under a microscope and initiate timely treatment.
Our patient was treated with a single injection of ceftriaxone, a single dose of oral azithromycin, and symptoms improved 10 days later.
Footnotes
Competing interests: The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: none.
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Patient consent obtained.
Provenance and peer review: Not commissioned; externally peer reviewed.