Gonococcal keratoconjunctivitis
A. Obtain initial culture results from the referring physician
Given persistent marked purulence and stromal necrosis, the negative culture results were surprising. However, these microbiology studies were obtained while the patient was receiving broad-spectrum topical antibiotic therapy. Initial culture results were obtained from the referring physician (choice A), which grew Neisseria gonorrhoeae. The patient then disclosed that his partner recently had a penile ulcer. He was immediately treated with saline lavages and single doses of intramuscular ceftriaxone sodium, 1 g, and oral azithromycin, 1 g, for gonococcal keratoconjunctivitis.
Although this patient was initially transferred with concern for a traumatic ruptured globe, the history of prior tree trauma was a red herring. The persistent purulence and corneal stromal necrosis raised concern for infection. Yield of ocular surface cultures are decreased when samples are obtained with concurrent topical antimicrobial therapy.1 This case also emphasizes the potential importance of follow-up on primary data. When patients are transferred between institutions with different medical record systems, information can be lost. Serologic workup for autoimmune keratitis (choice B) is not the preferred answer because the hyperpurulence and beefy conjunctival injection would be atypical for this sterile inflammatory presentation. Starting empirical treatment for acanthamoeba (choice C) is incorrect because hyperpurulence is unusual in acanthamoeba keratitis, and the patient had no freshwater risk factors or history of contact lens wear. With progressive corneal necrosis, returning to the operating room for therapeutic keratoplasty (choice D) may have been required; however, the initial best step in management is to obtain confirmative diagnosis.