Gonococcal ocular infection can be divided into two distinct forms, one affecting neonates and the other affecting sexually active adults. Most cases occur in neonates or sexually active adults and are transmitted by contact with infected urine or genital secretions. Recently, the incidence of adult gonococcal conjunctivitis has shown a tendency toward increasing with time, especially penicillinase-producing N. gonorrhoeae (PPNG).1,2

As gonococcal eye infection in adults is relatively rare, the clinical diagnosis may be delayed. However, it is very important that a prompt confirmatory culture for isolation of gonococcal organisms and earlier parenteral antibiotic treatment is required, because the outcome of gonococcal conjunctivitis is related to the severity of disease at the start of adequate therapy.3

We present a rare case of bilateral gonococcal conjunctivitis with keratitis, gram-negative intracellular diplococci, penicillin-resistant Neisseria gonorrhoeae, associated with a sexual history of relations with a prostitute.

Case report

A 29-year old man presented redness and ocular discharge from both eyes for 13 days before admission to Pusan National University Hospital in Pusan city. At first, the left conjunctiva was markedly inflamed and there was intense dilatation of the conjunctival vessels without small petechial hemorrhages with purulent exudates. The right eye was completely normal. The other eye became involved on the 7th day after left conjunctivitis developed. Eventually, he failed to respond, so was referred to our clinic for proper management of mucopurulent conjunctivitis.

He had a distinctive sexual contact history with a prostitute 17 days previously, but there was no evidence of genitourinary symptoms. On the day of admission, visual acuity was 20/40 in the right eye and 20/20 in the left. The right stromal cornea was mildly diffusely hazy with an epithelial defect just in the central portion, and the conjunctival signs were markedly inflamed with a purulent discharge in the left eye (Figure 1).

Figure 1
figure 1

At first visit, a keratitis with corneal epithelial defect in the right eye and injected conjunctivitis with purulent discharge in the left eye were present.

Initial laboratory examination consisted of conjunctival scrapings for Gram stain, and conjunctival cultures on chocolate, blood, phenylethyl alcohol with 5% sheep blood, and MacConkey media, all incubated at 37°C. Chocolate medium was incubated in a 5–10% carbon dioxide-enriched environment. This patient, with gram-negative intracellular diplococci bilaterally on gram stain, subsequently had positive conjunctival cultures for N. gonorrhoeae (Figure 2). Sensitivity studies showed the organism to be resistant to penicillin but sensitive to 3rd cepharosporin. Further, we performed the diagnostic test of sexually transmitted diseases such as direct fluorescent antibody testing for chlamydia and a serum rapid plasma reagin test for syphilis, but did not find any positive signs.

Figure 2
figure 2

There were many intracellular diplococci (Neisseria gonorrhea) with gram-negative staining in culture media.

Single dose treatment was begun with 1 g of intramuscular ceftriaxone (RocephinR) for 5 days and topical cefmenoxime 0.5% (BestronR) every 30 min for 2 days. Within 24 h, this patient responded clinically with marked reduction of ocular discharge and inflamed conjunctiva. Repeated conjunctival culture for 12 h after topical and systemic therapy was negative for N. gonorrhoeae. On the 3rd hospital day, cefmenoxime 0.5% (BestronR) was tapered every 2 h for 2 days, and every 6 h for 10 days. A 7-day course of doxycycline 100 mg was administered to prevent activity of collagenase released from destructive corneal lesions.

This patient was discharged after 5 days of intramuscular ceftriaxone (RocephinR). Three weeks after discharge, this patient had a visual acuity of 20/20 in both eyes without any complications of the conjunctiva and cornea (Figure 3). Currently, there is no evidence of serious complications of the cornea and conjunctiva.

Figure 3
figure 3

After the antibiotics were initiated for 3 weeks, the cornea was normal without corneal epithelial defect and corneal opacity in the right eye and the conjunctiva was normal in the left eye.


N. gonorrhoeae in adults causes an extremely profuse, hyperacute purulent discharge accompanied by severe conjunctival chemosis and intense dilatation of the conjunctival vessels without small petechial hemorrhages, eyelid swelling, and epithelial or stromal keratitis.1 The degree of corneal involvement is highly variable, but common types are marginal corneal melt, subepithelial or stromal infiltrates, and a discrete edema of the entire surface of the cornea.3

The incubation period of gonococcal ocular infection generally ranges from 3–19 days, and the urethral symptoms precede the ocular symptoms from one to several weeks.1 Compared with typical gonococcal keratoconjunctivitis, this case has some atypical findings such as localized stromal infiltrates with epithelial defect in the central cornea, no dysuria or urethral discharge, and a relatively long incubation period.

If inadequately treated, gonococcal conjunctivitis can progress in an extremely rapid and fulminant fashion, leading to corneal perforation within 24 h. If aggressive parenteral antibiotic therapy is instituted before severe corneal destruction occurs, it appears that the risk of serious sequelae and visual loss is greatly reduced. Therefore, the Centers for Disease Control issued the recommendation that all patients with adult gonococcal conjunctivitis be treated with hospitalization and a 5-day course of high doses of parenterally administered antibiotics like penicillin or cephalosporin therapy.4,5,6

The local incidence of PPNG currently represents less than 1% of all gonococcal infections.7 To initiate adequate antibiotics therapy is clinically important, because the outcome of gonococcal conjunctivitis is related to the severity of disease at the start of adequate therapy.

For the treatment of PPNG conjunctivitis, the Centers for Disease Control recommend the administration of 1.0 g of cefoxitin or 500 mg of cefotaxime intravenously four times daily, or 1.0 g of ceftriaxone intramuscularly daily, for 5 days.4,5,8 The World Health Organization recommends cefotaxime 1.0 g intravenously four times daily for 5 days or intramuscularly spectinomycin 2.0 g for 3 days.9 Recently, oral norfloxacin 1200 mg for 3 consecutive days may be a useful alternative for the treatment of adult gonococcal keratoconjunctivitis, especially for penicillin-resistant strains.1 We started with 1.0 g of ceftriaxone intramuscularly daily for 5 days, because this PPNG organism was sensitive to 3rd cephalosporin.

Frequently ocular saline lavage and topical antibiotics have been recommended as ancillary therapy in the treatment of gonococcal ophthalmia, but are not essential for successful treatment of N. gonorrhoeae conjunctivitis in adults.10 This patient was administered a topical 0.5% BestronR, because we feel strongly that aggressive topical antibiotics should be used to cure ocular lesions. Also we started with doxycycline 100 mg orally once daily for 1 week, to prevent activity of collagenase released from destructive corneal lesions,11 or to treat possible coexistent chlamydial infection with a false negative response by laboratory test.12

The rising incidence of PPNG strains and the increasing number of isolates with a high-level resistance to penicillin should lead us to suggest that a prompt confirmatory culture for isolation of PPNG organisms and a sensitivity test to antibiotics are elementary.1,2 When a case with sexual contact history is suspected of being a hyperacute purulent conjunctivitis or bacterial conjunctivitis refractory to primary antibiotic eye drops, a prompt confirmatory culture for isolation of gonococcal organisms and earlier parenteral antibiotic treatment are mandatory.