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Corneal Melting Caused by Neisseria gonorrhoeae in an Adolescent

Claiborne, Mary Kate MD; Atkinson, Joshua MS IV; Hoy, Austin MS IV; McBeth, Katrina MD

The Pediatric Infectious Disease Journal: March 2015 - Volume 34 - Issue 3 - p 330
doi: 10.1097/INF.0000000000000583
Letters to the Editor
Free

The University of Texas Medical School at Houston, Houston, Texas

The authors have no funding or conflicts of interest to disclose.

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To the Editors:

We treated a 17-year-old Hispanic male who had a 7-day history of left eye pain with movement, edema, decreased vision and copious purulent drainage caused by Neisseria gonorrhoeae. He had been evaluated 3 times at other hospitals where he was treated with gentamicin eye drops for 4 days and then artificial tears for 2 days with worsening symptoms. The patient was otherwise healthy. Evaluation of his social history revealed multiple sexual partners over the course of a 1-month period occasionally without protection and did not have any knowledge of possible gonococcal infection in sexual partners.

The patient had a fever of 101.2°F and was in mild distress. The left eye was remarkable for external erythema, conjunctival erythema, tenderness to touch and milky discharge from his eye. Genitourinary examination did not reveal any rashes, lesions or discharge. An ophthalmologic examination on hospital day 2 revealed a corneal lesion with a tetrahedral area of 2.5 × 1×1 mm with 10% of thickness remaining. The rest of the physical examination was normal.

A computed tomography scan performed on admission revealed left preseptal cellulitis with no drainable postseptal fluid collection evident. Culture of left eye purulent drainage was positive for N. gonorrhoeae and negative for Chlamydia trachomatis. Urine DNA amplification was weakly positive for N. gonorrhoeae and negative for C. trachomatis.

The boy was treated with oral doxycycline, copious irrigation with artificial tears and moxifloxacin ophthalmic drops. For corneal melting, he was treated with prednisolone drops and oral vitamin C. Patient was discharged home after 5 hospital days with moxifloxacin ophthalmic drops, oral doxycycline and oral vitamin C with instructions to wear an eye shield while sleeping.

At a 1-month follow-up, there was a 1.7 × 1.3 × 1.5 mm area of epithelialization over the corneal defect.

Gonococcal conjunctivitis is very rare outside of the neonatal period. There has been 1 other published case of periorbital cellulitis caused by N. gonorrhoeae in a child, 1 reported case of gonococcal orbital cellulitis in an adolescent, and 2 reported cases of gonococcal preseptal cellulitis in adults.1–4

Unlike other bacterial infections, N. gonorrhoeae is able to penetrate intact corneal epithelium causing corneal melt, which occurred in our patient. This destruction of the epithelium and stroma can quickly lead to vision loss or corneal perforation that might require corneal grafting.6,7

Mary Kate Claiborne, MD

Joshua Atkinson, MS IV

Austin Hoy, MS IV

Katrina McBeth, MD

The University of Texas Medical

School at Houston

Houston, Texas

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REFERENCES

1. Upile NS, Munir N, Leong SC, et al. Who should manage acute periorbital cellulitis in children? Int J Pediatr Otorhinolaryngol. 2012;76:1073–1077
2. Frazier JJ, Miller J, Pickering LK. Orbital cellulitis due to Neisseria gonorrhoeae in an enucleated socket. Arch Ophthalmol. 1979;97:2345
3. Green JA, Lim J, Barkham T. Neisseria gonorrhoeae: a rare cause of preseptal cellulitis? Int J STD AIDS. 2006;17:137–138
4. Henderson TR, Booth AP, Morrell AJ. Neisseria gonorrhoeae: a previously unreported cause of pre-septal cellulitis. Eye (Lond). 1997;11(Pt 1):130–132
5. Hauser A, Fogarasi S. Periorbital and orbital cellulitis. Pediatr Rev. 2010;31:242–249
6. Tipple C, Smith A, Bakowska E, et al. Corneal perforation requiring corneal grafting: a rare complication of gonococcal eye infection. Sex Transm Infect. 2010;86:447–448
7. Day AC, Ramkissoon YD, George S, et al. Don’t forget gonococcus! Eye (Lond). 2006;20:1400–1402
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