Gonococcal conjunctivitis (GC) or occular gonorrhea is an infection which occurs when neonates’ eyes come in contact with infected genital secretions from a person with genital gonorrhoea infection. It is also known as gonococcal ophthalmia neonatorum. During the physical examination, the patients often present with conjunctival chemosis, periauricular lymphadenopathy, oedema of the eyelids, discharge and tenderness of the globe. The findings further raise the suspicion of gonococcal conjunctivitis.
Gonococcal conjunctivitis is typically known as a disease in neonates. However, this is now also a pressing infectious process in other age groups. GC in neonates is also referred to as gonococcal ophthalmia neonatorum. It is most likely transmitted from an infected mother during birth. In older age groups it is generally associated with sexually transmitted infections but can also occur in the absence of concomitant genital infection. Untreated cases can lead to significant life-threatening conditions, such as meningitis or blindness. Thus, it is important to diagnose and treat the condition .
GC is generally caused because of an ophthalmic infection with Neiserria gonorrhea, a gram-negative diplococcus. The infection can spread via vaginal secretions during delivery because the mucosa of the cervix and urethra acts as a bacterial reservoir. Even with delivery via cesarean section, vertical transmission of infections is possible. Approximately 10% of neonates who are exposed to gonorrheal exudates during delivery may develop GC. This may occur even with appropriate prophylaxis. However, in other than neonates, the transmission may occur via direct sexual contact either through infective secretions or indirectly through manual or fomite transmission. Although, studies have shown that N. gonorrhea does not survive more than a few minutes outside the human body. Further evidence has shown that GC could occur because of different strains of gonococci that are not associated with STIs .
Statistics show that the incidence of gonococcal infections is less than 1% in newborns. The incidence tends to be lower in developing countries because of the wide availability of screening and treatment options. However, the rates are significantly higher in developing countries because the rate of gonococcal infection in pregnancy averages 5%. Whereas the incidence of conjunctivitis ranges from 1% to 2% and in neonates the incidence is estimated to be less than 1%. Similarly, in neonates, even with appropriate prophylaxis, 10% may still develop GC compared to the 48% that do not .
GC is rare in the non-neonatal population. The STI surveillance team in the U.S. estimates that nearly 146 cases of gonorrhoea are reported in every 100,000 people. However, there is not enough data on the prevalence of GC. According to a recent study conducted in Ireland, the prevalence of GC is 0.19 cases per 1000 patients that were evaluated for eye emergencies. A majority of the patients were young adult males .
Case study: Occular Gonorrhea
In this article, we describe the case of a 24-year-old who presented to the emergency department with redness, yellow discharge, blurry vision and pain in her left eye with a history of 2 days. Her medical history did not reveal any signs of sore throat, joint pain, rash, abdominal pain, vaginal discharge or dysuria. On examination, the patient was unable to open her left eye. The examination further showed periorbital swelling, purulent discharge and proptosis. Other findings included a hyperemic, swollen and purulent conjunctiva.
There were no abnormal extraocular movements. For further evaluation, doctors referred the patient for a computed tomography of the orbits without administration of contrast material. The findings showed postseptal inflammation of the left orbit extending to the extraconal and intraconal fat. Gram-staining of the discharge showed the growth of gram-negative intracellular diplococci. Interestingly, fluid culture showed the growth of Neisseria gonorrhoeae. Based on these findings, doctors diagnosed the patient with gonococcal conjunctivitis with preceptal and orbital cellulitis. PCR assay of the patient’s urine was negative for gonorrhea. The doctors did not collect cervical, rectal or pharyngeal samples. The patient was further negative for other STDs. Treatment includes intravenous antibiotics after which the symptoms resolved .
N. gonorrheae can attach to and penetrate the muscosal surface epithelial cells, for example the conjunctiva. Once the bacteria penetrates the epithelial cells, it can proliferate and induce proinflammatory mechanisms. However, previous studies have shown that the bacteria can evade and even modulate an inflammatory response which can lead to disseminated infection, such as bacteremia or meningitis.
- Costumbrado, J., Ng, D.K. and Ghassemzadeh, S., 2021. Gonococcal conjunctivitis. In StatPearls [Internet]. StatPearls Publishing.
- Suyama, Y. and Akiyama, R., 2022. Ocular Gonorrhea. New England Journal of Medicine, 386(17), p.e46.