Figure 1. Patient presents with painful watery right eye
Medical Student (MBBS V)
Monash University, VIC
Infectious conjunctivitis is a commonly presenting complaint to health professionals globally.1 Most conjunctivitis presentations are viral in origin, self-limiting and require only topical palliative therapy such as lubricants. We present a case of non-invasive primary meningococcal conjunctivitis (PMC) identified on retrospective Gram-stain and culture diagnosis.
Australia is currently experiencing a rise in the notifications of Neisseria meningitidis serogroup W (MenW).2 In 2014, there were 17 notified cases of MenW. That number rose to 34 in 2015 and 110 in 2016.3 Although the most common presentation of MenW is septicaemia, localised disease also occurs, including septic arthritis, epiglottitis, pneumonia and pericarditis.2,3 Although rare, especially in adults, PMC is potentially vision and life-threatening.4,5 This report reminds health professionals of the current meningococcal W outbreak in Australia and the possible consequences of PMC.
A 19-year-old Caucasian male presented to a metropolitan emergency department (ED) in Victoria, having experienced pain and copious watery discharge from his right eye for six hours.
He complained of a unilateral red eye, mild visual disturbance and foreign body sensation which worsened on removal of contact lenses which had been in place for two weeks.
He had experienced a coryzal (catarrhal inflammation of the mucous membrane in the nose) illness a week prior to his presentation, which had resolved. He had no meningism (symptoms similar to those of meningitis but not caused by meningitis), fever, rashes or other symptoms. Apart from hypermetropia (he wore monthly contact lenses), he had no past medical history. He was an active cyclist and university student who lived with his family.
On examination, unaided Snellen visual acuity was 6/6 bilaterally, with mild peri-orbital swelling and global scleral injection in the right eye. Slitlamp examination revealed widespread chemosis, significant epiphora, marked hyperaemia, a minor anterior chamber reaction (0.5+ of cells) and follicular response in the affected eye. Multiple corneal punctate epithelial erosions were present. There was no periauricular lymphadenopathy and vital signs were normal. His left eye was unremarkable.
Due to the severity of his chemosis, a swab was sent for Gram-stain and culture. The intensity of conjunctival chemosis and other signs indicated that the pathology was not related to contact lens wear, but this could not be entirely ruled out. The patient was discharged on topical lubricants with presumed viral conjunctivitis.
Five days later, the patient was recalled to the emergency department and admitted because the culture grew Neisseria meningitidis serotype W (sensitive to ceftriaxone, chloramphenicol, ciprofloxacin and penicillin). The patient was completely asymptomatic at this time. His haematology and biochemistry results were normal. He commenced topical chloramphenicol 0.5% every two hours and 2 g intravenous ceftriaxone twice daily. Contact tracing and chemoprophylaxis with 500 mg ciprofloxacin was initiated and the health authorities were notified.
The patient was discharged following normal ophthalmic review and blood cultures, after receiving two days of intravenous ceftriaxone. He continued topical chloramphenicol for a further five days.
Figure 2. Patient following two days of intravenous ceftriaxone and five days of topical chloramphenicol
Neisseria meningitidis is an uncommon but potentially dangerous cause of bacterial conjunctivitis.6 PMC is extremely rare in adults, with only 20 cases reported before 1990.4 Even in children, it is an uncommon cause of bacterial conjunctivitis, accounting for only two per cent of cases in a review of 1,030 children with acute bacterial conjunctivitis.7 Meningococcal conjunctivitis can be divided into primary (exogenous) and secondary (endogenous) disease, where the latter is a complication of systemic meningococcal disease.6,7
PMC typically presents abruptly with associated burning sensation, irritation, epiphora and yellow-green purulent discharge from the affected eye, similar to Neisseria gonorrhoeae.5 Low fevers are present in 24 per cent of PMC cases and enlarged regional lymph nodes in 14 per cent.4 Our patient presented atypically and mimicked epidemic viral conjunctivitis. However, one case report in the ophthalmology literature reported a similar case with a retrospective culture diagnosis.4
There are 13 Neisseria meningitidis serogroups: A, B, C, W and Y most commonly cause disease.3 Until recently, serogroup B (MenB) was the most common cause of invasive meningococcal disease in Australia, accounting for 63 per cent to 88 per cent of annual notified cases from 2006 to 2015.3 However, in 2016 there were 110 notified MenW cases, surpassing MenB (92 cases).3 MenW also appears to have a higher case fatality rate than disease caused by other serogroups.3
There are currently three types of meningococcal vaccines available in Australia: meningococcal C conjugate vaccine, multicomponent meningococcal B vaccine and quadrivalent (A, C, W, Y) meningococcal conjugate vaccines.3 It is important to note that there is no single vaccine which covers all five common serogroups.
With the recent rise of MenW, the quadrivalent meningococcal vaccine is now being funded in Victoria, Queensland, New South Wales and Western Australia in 2017 for adolescents aged 15-19 years.3 Readers should consult the respective state or territory health department website for further details.
Humans are the only natural hosts of Neisseria meningitidis and about one in 10 is an asymptomatic carrier.8,9 It is a normal flora of the oropharynx but not of the eye.10 Prevalence and duration of carriage vary over time and in different populations and age groups, with peak carriage rates (> 20 per cent) occurring in adolescents.3 Most meningococcal cases in Australia tend to occur during early spring or winter.3 Meningococcal bacteria are transmitted in respiratory droplets and the risk of transmission increases with prolonged close contact with those infected.3
Meningococcal disease tends to affect people who are immunocompromised (from age, disease or treatment), asplenic, experiencing recent or current viral upper respiratory tract infection or live in crowded conditions.3 The literature has also cited the extended wear of contact lenses to be a risk factor for microbial keratitis, especially with Gram-negative organisms.11,12,13 Although not specific to conjunctivitis, this finding raises the possibility of an increased risk of microbial conjunctivitis in our patient who had had his contact lenses in place for two weeks.
Possible local complications of PMC include corneal ulceration, iritis, keratitis and subconjunctival haemorrhage.5,7 It can cause blindness and progress to systemic disease (18 per cent), being fatal in 13 per cent of those with systemic disease.7 There is limited information in the international literature regarding PMC and it raised several questions regarding appropriate treatment of the patient.
Patients treated solely with topical antibiotics have a 19-fold increased risk of developing systemic disease compared to those treated with topical and systemic antibiotics.7 Doctors should consult their local infectious diseases physician or hospital guidelines for specific treatment options. This report reminds us of the current MenW outbreak in Australia and raises awareness of the possibility of atypical presentations of this disease.
Optometrists in particular should consider this in any atypical anterior eye presentation and consider conjunctival swabbing as part of their work-up.
- Daud J, Ishak SR, Deris ZZ, Hitam WHW. Excellent outcome of primary Neisseria meningitidis keratoconjunctivitis. Asian Pac J Trop Biomed 2011; 1: 5: 419-420.
- Australian Government Department of Health. Meningococcal W Disease. Canberra: Commonwealth of Australia, 2017. Accessed June 2017. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/ohp-meningococcal-W.htm.
- Centre for Immunisation Research & Surveillance. Meningococcal vaccines for Australians fact sheet. New South Wales: Centre for Immunisation Research & Surveillance, 2017. Accessed June 2017. Available from: http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/meningococcal-vaccines-fact-sheet.pdf.
- Andreoli C, Wiley H, Durand M, Watkins L. Primary meningococcal conjunctivitis in an adult. Cornea 2004; 23: 7: 738-39.
- Morrow G, Abbott R. Conjunctivitis. Am Fam Physician 1998; 57: 4: 735-746.
- Orden B, Martínez R, Millán R, Belloso M, Pérez N. Primary meningococcal conjunctivitis. Clin Microbiol Infec 2003; 9: 1245-1247.
- Barquet N, Gasser I, Domingo P et al. Primary meningococcal conjunctivitis: report of 21 patients and review. Rev Infect Dis 1990; 12: 5: 838-847.
- Swain CL, Martin DR. Survival of meningococci outside of the host: implications for acquisition. Epidemiol Infect 2007; 135: 2: 315-320.
- Centers for Disease Control and Prevention. Meningococcal Disease. Atlanta: Centers for Disease Control and Prevention, 2017. Accessed June 2017. Available from: https://www.cdc.gov/meningococcal/about/causes-transmission.html.
- Davis CP. Normal flora. In: Baron S, ed. Medical Microbiology, 4th edn. Galveston: University of Texas Medical Branch, 1996. Available from: https://www.ncbi.nlm.nih.gov/books/NBK7617/.
- Dart JK. Predisposing factors in microbial keratitis: the significance of contact lens wear. Br J Ophthalmol 1988; 72: 12: 926-930.
- Lim L, Loughnan MS, Sullivan LJ. Microbial keratitis associated with extended wear of silicone hydrogel contact lenses. Br J Ophthalmol 2002; 86: 3: 355-357.
- Al-Mujaini A, Al-Kharusi N, Thakral A, Wali UK. bacterial keratitis: perspective on epidemiology, clinico-pathogenesis, diagnosis and treatment. Sultan Qaboos Univ Med J 2009; 9: 2: 184-195.