Case Presentation: A 10 year old female presented to the emergency department with 2 days of rapidly progressive left eye pain, purulent drainage, foreign body sensation, painful eye movements and left sided headache. Physical exam revealed moderate left eyelid edema with tenderness, conjunctival injection and copious purulent discharge. She had no leukocytosis or neutrophilia. CT Orbits revealed acute conjunctivitis, preseptal cellulitis, and a gas forming, rim enhancing 4 mm fluid collection consistent with anterior conjunctival phlegmon. She was treated with high dose ceftriaxone initially but given her history of prior methicillin resistant staphylococcus aureus skin abscess, she was transitioned to IV clindamycin. She was additionally given systemic prednisolone as her eyelid edema prevented the application of ophthalmic dexamethasone. Her eyelid edema also prevented a full ophthalmologic evaluation to rule out corneal involvement. A culture of her eye drainage resulted positive for pan-sensitive Neisseria Gonorrhoeae. A full sexually transmitted infection panel was conducted and revealed Neisseria Gonorrhoeae in her throat culture, all other testing was negative. Her treatment was promptly transitioned back to high dose Ceftriaxone to complete 5 days of treatment until her edema subsided enough to allow a full examination to rule out corneal involvement. She was empirically treated with 7 days of doxycycline for presumptive chlamydia co-infection, which was later ruled out. Further investigations were conducted by a Child Abuse specialist and the Department of Children and Families, which did not reveal any clear evidence of sexual abuse after several weeks of follow up.
Discussion: The common pathogens for pediatric acute conjunctivitis include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Conjunctivitis is typically treated topically either with macrolides, sulfonamides, polypeptides, or fluoroquinolones. The American College of Ophthalmology states cultures for routine conjunctivitis are rarely helpful. The identification of gonococcal conjunctivitis is crucial though given the rise in fluoroquinolone resistance in Neisseria gonorrhoeae, prompting the need for treatment with high dose ceftriaxone. Gonorrhea is the second most reported bacterial communicable disease in adolescents so it is easy to consider gonorrhea as the cause of purulent conjunctivitis in teenagers.However, 1 in 4 girls and 1 in 20 boys in the U.S. experience child sexual abuse and 75% of abuse occurs before the age of 12. Although this particular case didn’t result in clear evidence of abuse, it is vital we don’t exclude the child/pre-adolescent population from consideration for gonococcal infection in cases of rapidly progressive purulent conjunctivitis because delays in treatment can lead to blindness, meningitis, and missing a case of abuse. Obtaining an eye culture in highly purulent conjunctivitis is an easy, cost-effective way to identify these higher risk cases.
Conclusions: This case highlights the importance of considering gonorrhea as a cause of rapidly progressive purulent conjunctivitis in children, rather than just adolescents, and confirming the diagnosis with eye culture. Prompt treatment with Ceftriaxone can lead to sight preservation, and quick diagnosis will initiate a thorough investigation to ensure the child’s safety.