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Purulent Conjunctivitis and Progressive Corneal Stromal Necrosis

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 65-year-old man presented with worsening right eye pain and purulent discharge. He reported being hit in the face by a tree branch several days prior. His medical history was notable for HIV, with a last known CD4 lymphocyte count of 112 cells/mm3 and variable adherence to antiretroviral therapy. At an outside hospital, cultures were obtained, and treatment was initiated with ofloxacin eye drops, 0.3%, ciprofloxacin hydrochloride ointment, 0.3%, and oral moxifloxacin hydrochloride, 400 mg daily. His symptoms worsened, and he was referred 3 days later for further evaluation.

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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.

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Article Information

Corresponding Author: Gerami D. Seitzman, MD, Department of Ophthalmology, University of California San Francisco, Francis I. Proctor Foundation, 490 Illinois St, San Francisco, CA 94158 (gerami.seitzman@ucsf.edu).

Published Online: June 3, 2021. doi:10.1001/jamaophthalmol.2020.5442

Conflict of Interest Disclosures: Dr Seitzman reported serving as a paid consultant to Dompé unrelated to the scope of this work. No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Lin  A , Rhee  MK , Akpek  EK ,  et al; American Academy of Ophthalmology Preferred Practice Pattern Cornea and External Disease Panel.  Bacterial Keratitis Preferred Practice Pattern®.   Ophthalmology. 2019;126(1):1-P55. doi:10.1016/j.ophtha.2018.10.018 PubMedGoogle ScholarCrossref
2.
Belga  S , Gratrix  J , Smyczek  P ,  et al.  Gonococcal conjunctivitis in adults: case report and retrospective review of cases in Alberta, Canada, 2000-2016.   Sex Transm Dis. 2019;46(1):47-51. doi:10.1097/OLQ.0000000000000897 PubMedGoogle ScholarCrossref
3.
McAnena  L , Knowles  SJ , Curry  A , Cassidy  L .  Prevalence of gonococcal conjunctivitis in adults and neonates.   Eye (Lond). 2015;29(7):875-880. doi:10.1038/eye.2015.57 PubMedGoogle ScholarCrossref
4.
Ullman  S , Roussel  TJ , Forster  RK .  Gonococcal keratoconjunctivitis.   Surv Ophthalmol. 1987;32(3):199-208. doi:10.1016/0039-6257(87)90095-6 PubMedGoogle ScholarCrossref
5.
Wan  WL , Farkas  GC , May  WN , Robin  JB .  The clinical characteristics and course of adult gonococcal conjunctivitis.   Am J Ophthalmol. 1986;102(5):575-583. doi:10.1016/0002-9394(86)90527-1 PubMedGoogle ScholarCrossref
6.
Gonococcal infections in adolescents and adults. 2015 STD Treatment Guidelines. Centers for Disease Control and Prevention. Accessed June 7, 2020. https://www.cdc.gov/std/tg2015/gonorrhea.htm
7.
Costumbrado  J , Ng  DK , Ghassemzadeh  S . Gonococcal Conjunctivitis. In: StatPearls [Internet]. StatPearls Publishing; 2020. Accessed May 28, 2020. https://www.ncbi.nlm.nih.gov/books/NBK459289/
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