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Primary meningococcal conjunctivitis

2003; Elsevier BV; Volume: 9; Issue: 12 Linguagem: Inglês

10.1111/j.1469-0691.2003.00799.x

1469-0691

B Orden, Ricardo Martinez, Rosario San Millàn, Marta Sabanza Belloso, N Pérez,

Infective Endocarditis Diagnosis and Management

Neisseria meningitidis is an uncommon cause of acute bacterial conjunctivitis. One case of primary meningococcal conjunctivitis in a healthy 6-year-old boy is reported. The patient was initially treated with a topical instillation of polymyxin B, neomycin and gramicidin in ophthalmic solution, and this was followed by systemic rifampin once the diagnosis had been established. No ocular or systemic complications developed. Neisseria meningitidis is an uncommon cause of acute bacterial conjunctivitis. One case of primary meningococcal conjunctivitis in a healthy 6-year-old boy is reported. The patient was initially treated with a topical instillation of polymyxin B, neomycin and gramicidin in ophthalmic solution, and this was followed by systemic rifampin once the diagnosis had been established. No ocular or systemic complications developed. Neisseria meningitidis is an uncommon cause of acute bacterial conjunctivitis. However, its diagnosis has important therapeutic implications. Acute conjunctivitis caused by N. meningitidis is classified into primary (exogenous) and secondary (endogenous) disease [1Barquet N Gasser I Domingo P Moraga FA Macaya A Elcuaz R Primary meningococcal conjunctivitis. Report of 21 patients and review.Rev Infect Dis. 1990; 12: 838-847Crossref PubMed Scopus (61) Google Scholar]. Primary meningococcal conjunctivitis (PMC) can occur in two forms: invasive and non-invasive [2Andersen J Lind I Characterization of Neisseria meningitidis isolates and clinical features of meningococcal conjunctivitis in ten patients.Eur J Clin Microbiol Infect Dis. 1994; 13: 388-393Crossref PubMed Scopus (14) Google Scholar]. In the former, meningococcal conjunctivitis may represent the portal of entry of N. meningitidis, and is followed by systemic meningococcal disease after a variable interval of time [3Moraga Llop FA Barquet Esteve N Domingo Pedrol P Gallart Catala A Primary meningococcal conjunctivitis: implications beyond the conjunctiva.Med Clin (Barc). 1996; 107: 130-132PubMed Google Scholar]. In the latter, the conjunctivitis occurs as an isolated phenomenon [2Andersen J Lind I Characterization of Neisseria meningitidis isolates and clinical features of meningococcal conjunctivitis in ten patients.Eur J Clin Microbiol Infect Dis. 1994; 13: 388-393Crossref PubMed Scopus (14) Google Scholar]. Secondary meningococcal conjunctivitis occurs as an unusual complication of systemic meningococcal disease [4Newton DA Wilson WG Primary meningococcal conjunctivitis.Pediatrics. 1977; 60: 104-106PubMed Google Scholar]. The true incidence of N. meningitidis conjunctivitis is unknown. This may be partly due to the fact that most patients with acute conjunctivitis are empirically treated without culture of the conjunctival exudate being done [1Barquet N Gasser I Domingo P Moraga FA Macaya A Elcuaz R Primary meningococcal conjunctivitis. Report of 21 patients and review.Rev Infect Dis. 1990; 12: 838-847Crossref PubMed Scopus (61) Google Scholar]. We recently observed a patient with primary unilateral meningococcal conjunctivitis. This case reinforces the need for bacteriologic identification of the etiologic agent in acute conjunctivitis in children, to avoid mismanagement. A healthy 6-year-old boy had a purulent discharge from the right eye with conjunctival injection, and eyelid edema of 3 days' duration. Examination at that time revealed that the child was normal except for his eye. The conjunctiva was red and edematous, with much yellow exudate. Erythema was present in both eyelids. The patient did not have fever or general malaise. He was diagnosed as having purulent conjunctivitis, and was treated at home with a local instillation of polymyxin B, neomycin and gramicidin in ophthalmic solution. Prior to treatment, a conjunctival swab was taken. A sample of eye secretion was inoculated onto Columbia blood agar and chocolate agar. A Gram stain of the exudate revealed many polymorphonuclear leukocytes and a moderate number of Gram-negative diplococci. The plates were incubated at 35–37 °C in an atmosphere containing 5% CO2, with daily observation for 2 days. A susceptibility test was performed for the main antimicrobial agents, by disk diffusion on GC agar base and 1% defined growth supplement, according to National Committee for Clinical Laboratory Standards (NCCLS) methods. After 48 h of incubation, an oxidase-positive, Gram-negative diplococcus was isolated and identified as N. meningitidis by API NH (bio-Merieux, Marcy-L'Etoile, France). This identification was confirmed by the Meningococcal Reference Laboratory, Instituto Carlos III (Madrid) as being N. meningitidis serogroup B, serotype NT, subtype p1.14, with a penicillin MIC of 0.015 mg/L. The susceptibility test showed that the microorganism was sensitive to rifampin, tetracycline, ceftriaxone and ciprofloxacin. At 48 h, the eye culture was reported to the pediatrician to have yielded N. meningitidis. The patient was contacted, and the results of physical examination were normal. Eye secretions had disappeared by the third day of topical treatment. The patient was further treated with oral rifampin for 3 days, 6 days after the appearance of the initial ocular symptoms; parenteral therapy was not used at home. Meningococcal prophylaxis with rifampin was prescribed for the sister and parents. Our patient has had no local complications, and nor has he developed systemic meningococcal disease after 2 months of follow-up. Acute conjunctivitis is the most common disorder of the eye seen by the primary care practitioner. Chlamydia trachomatis and Neisseria gonorrhoeae are the infectious agents that cause ophtalmia neonatorum [5Wald ER Conjunctivitis in infants and children.Pediatr Infect Dis J. 1997; 16: S17-S20Crossref PubMed Scopus (24) Google Scholar], but in children three organisms are isolated more frequently from cases of acute conjunctivitis: Haemophilus influenzae, Streptococcus pneumoniae, and adenoviruses [5Wald ER Conjunctivitis in infants and children.Pediatr Infect Dis J. 1997; 16: S17-S20Crossref PubMed Scopus (24) Google Scholar,6Syed NA Hyndiuk RA Infectious conjunctivitis.Infect Dis Clin North Am. 1992; 6: 789-805PubMed Google Scholar]. Staphylococcus aureus is common at any age, and can cause blepharitis and blepharoconjunctivitis [6Syed NA Hyndiuk RA Infectious conjunctivitis.Infect Dis Clin North Am. 1992; 6: 789-805PubMed Google Scholar]. Predisposing events for acquiring PMC include ocular trauma [1Barquet N Gasser I Domingo P Moraga FA Macaya A Elcuaz R Primary meningococcal conjunctivitis. Report of 21 patients and review.Rev Infect Dis. 1990; 12: 838-847Crossref PubMed Scopus (61) Google Scholar] and close contact with a meningococcal carrier or another patient with systemic meningococcal disease [1Barquet N Gasser I Domingo P Moraga FA Macaya A Elcuaz R Primary meningococcal conjunctivitis. Report of 21 patients and review.Rev Infect Dis. 1990; 12: 838-847Crossref PubMed Scopus (61) Google Scholar]. PMC is assumed to be due to the direct inoculation of N. meningitidis into the conjunctival sac from an exogenous source. The inoculation may take place through airborne microorganisms or manual contact [1Barquet N Gasser I Domingo P Moraga FA Macaya A Elcuaz R Primary meningococcal conjunctivitis. Report of 21 patients and review.Rev Infect Dis. 1990; 12: 838-847Crossref PubMed Scopus (61) Google Scholar]. The clinical manifestations of meningococcal conjunctivitis resemble those of other types of bacterial conjunctivitis. PMC is classically described as an acute or hyperacute purulent conjunctivitis that is accompanied by gross purulent exudate. The acute onset of unilateral purulent conjunctivitis in our patient was similar to that in most of the cases previously reported [1Barquet N Gasser I Domingo P Moraga FA Macaya A Elcuaz R Primary meningococcal conjunctivitis. Report of 21 patients and review.Rev Infect Dis. 1990; 12: 838-847Crossref PubMed Scopus (61) Google Scholar, 2Andersen J Lind I Characterization of Neisseria meningitidis isolates and clinical features of meningococcal conjunctivitis in ten patients.Eur J Clin Microbiol Infect Dis. 1994; 13: 388-393Crossref PubMed Scopus (14) Google Scholar, 3Moraga Llop FA Barquet Esteve N Domingo Pedrol P Gallart Catala A Primary meningococcal conjunctivitis: implications beyond the conjunctiva.Med Clin (Barc). 1996; 107: 130-132PubMed Google Scholar, 4Newton DA Wilson WG Primary meningococcal conjunctivitis.Pediatrics. 1977; 60: 104-106PubMed Google Scholar,7Neoh C Agious-Fernandez A Kaye SB Molyneux EM Hart CA Primary meningococcal conjunctivitis in children.Br J Clin Pract. 1994; 48: 27-28PubMed Google Scholar,8Stansfield RE Masterton RG Dale BA Fallon RJ Primary meningococcal conjunctivitis and the need for prophylaxis in close contacts.J Infect. 1994; 29: 211-214Abstract Full Text PDF PubMed Scopus (8) Google Scholar]. The incidence of N. meningitidis conjunctivitis is unknown. N. meningitidis accounted for 1.7% [3Moraga Llop FA Barquet Esteve N Domingo Pedrol P Gallart Catala A Primary meningococcal conjunctivitis: implications beyond the conjunctiva.Med Clin (Barc). 1996; 107: 130-132PubMed Google Scholar], 2% [7Neoh C Agious-Fernandez A Kaye SB Molyneux EM Hart CA Primary meningococcal conjunctivitis in children.Br J Clin Pract. 1994; 48: 27-28PubMed Google Scholar] and 2.4% [1Barquet N Gasser I Domingo P Moraga FA Macaya A Elcuaz R Primary meningococcal conjunctivitis. Report of 21 patients and review.Rev Infect Dis. 1990; 12: 838-847Crossref PubMed Scopus (61) Google Scholar] of the cases of bacterial conjunctivitis reported in the literature. After PMC, ocular complications occurred in 0% [2Andersen J Lind I Characterization of Neisseria meningitidis isolates and clinical features of meningococcal conjunctivitis in ten patients.Eur J Clin Microbiol Infect Dis. 1994; 13: 388-393Crossref PubMed Scopus (14) Google Scholar,3Moraga Llop FA Barquet Esteve N Domingo Pedrol P Gallart Catala A Primary meningococcal conjunctivitis: implications beyond the conjunctiva.Med Clin (Barc). 1996; 107: 130-132PubMed Google Scholar,7Neoh C Agious-Fernandez A Kaye SB Molyneux EM Hart CA Primary meningococcal conjunctivitis in children.Br J Clin Pract. 1994; 48: 27-28PubMed Google Scholar] and up to 15.5% [1Barquet N Gasser I Domingo P Moraga FA Macaya A Elcuaz R Primary meningococcal conjunctivitis. Report of 21 patients and review.Rev Infect Dis. 1990; 12: 838-847Crossref PubMed Scopus (61) Google Scholar] of the cases previously reported. The most frequent were corneal ulcers (69.2%); keratitis occurred in 15.4% [1Barquet N Gasser I Domingo P Moraga FA Macaya A Elcuaz R Primary meningococcal conjunctivitis. Report of 21 patients and review.Rev Infect Dis. 1990; 12: 838-847Crossref PubMed Scopus (61) Google Scholar], and subconjunctival hemorrhage or iritis was diagnosed in 7.7% [1Barquet N Gasser I Domingo P Moraga FA Macaya A Elcuaz R Primary meningococcal conjunctivitis. Report of 21 patients and review.Rev Infect Dis. 1990; 12: 838-847Crossref PubMed Scopus (61) Google Scholar]. Invasive meningococcal disease developed in 10–29.4% of the patients with PMC [1Barquet N Gasser I Domingo P Moraga FA Macaya A Elcuaz R Primary meningococcal conjunctivitis. Report of 21 patients and review.Rev Infect Dis. 1990; 12: 838-847Crossref PubMed Scopus (61) Google Scholar, 2Andersen J Lind I Characterization of Neisseria meningitidis isolates and clinical features of meningococcal conjunctivitis in ten patients.Eur J Clin Microbiol Infect Dis. 1994; 13: 388-393Crossref PubMed Scopus (14) Google Scholar, 3Moraga Llop FA Barquet Esteve N Domingo Pedrol P Gallart Catala A Primary meningococcal conjunctivitis: implications beyond the conjunctiva.Med Clin (Barc). 1996; 107: 130-132PubMed Google Scholar], and symptoms of systemic meningococcal disease appeared at a mean interval of 41.3 ± 30.5 h (range 3–96 h) after appearance of the initial ocular symptoms [1Barquet N Gasser I Domingo P Moraga FA Macaya A Elcuaz R Primary meningococcal conjunctivitis. Report of 21 patients and review.Rev Infect Dis. 1990; 12: 838-847Crossref PubMed Scopus (61) Google Scholar]. The treatment of PMC should include combined topical and systemic therapy [1Barquet N Gasser I Domingo P Moraga FA Macaya A Elcuaz R Primary meningococcal conjunctivitis. Report of 21 patients and review.Rev Infect Dis. 1990; 12: 838-847Crossref PubMed Scopus (61) Google Scholar,2Andersen J Lind I Characterization of Neisseria meningitidis isolates and clinical features of meningococcal conjunctivitis in ten patients.Eur J Clin Microbiol Infect Dis. 1994; 13: 388-393Crossref PubMed Scopus (14) Google Scholar], in view of the potential for invasiveness of N. meningitidis, with appropriate chemoprophylaxis for close contacts of the patients [2Andersen J Lind I Characterization of Neisseria meningitidis isolates and clinical features of meningococcal conjunctivitis in ten patients.Eur J Clin Microbiol Infect Dis. 1994; 13: 388-393Crossref PubMed Scopus (14) Google Scholar,8Stansfield RE Masterton RG Dale BA Fallon RJ Primary meningococcal conjunctivitis and the need for prophylaxis in close contacts.J Infect. 1994; 29: 211-214Abstract Full Text PDF PubMed Scopus (8) Google Scholar]. Forty-one per cent of the patients who received only topical therapy, and none of those who received systemic therapy, developed invasive meningococcal disease [3Moraga Llop FA Barquet Esteve N Domingo Pedrol P Gallart Catala A Primary meningococcal conjunctivitis: implications beyond the conjunctiva.Med Clin (Barc). 1996; 107: 130-132PubMed Google Scholar], and 93% of the patients with PMC and secondary systemic disease had received only topical therapy [1Barquet N Gasser I Domingo P Moraga FA Macaya A Elcuaz R Primary meningococcal conjunctivitis. Report of 21 patients and review.Rev Infect Dis. 1990; 12: 838-847Crossref PubMed Scopus (61) Google Scholar]. Systemic antibiotic therapy should be mandatory for all patients with PMC, although topical antibiotics can be used as an adjunct to systemic therapy [1Barquet N Gasser I Domingo P Moraga FA Macaya A Elcuaz R Primary meningococcal conjunctivitis. Report of 21 patients and review.Rev Infect Dis. 1990; 12: 838-847Crossref PubMed Scopus (61) Google Scholar]. Systemic therapy is the norm for meningococcal systemic disease: intravenous penicillin G 300 000 IU/kg per day, up to 24 million IU/day. Intravenous cefotaxime, 200 mg/kg per day or intravenous ceftriaxone, 100 mg/kg per day are used in countries where the prevalence of moderately penicillin-resistant meningococci is high (in Spain, a level of 20% was reported in 1989 [9Saez-Nieto JA Lujan R Berrón S et al.Epidemiology and molecular basis of penicillin-resistant Neisseria meningitidis in Spain: a 5-year history (1985-1989).Clin Infect Dis. 1992; 14: 394-402Crossref PubMed Scopus (120) Google Scholar]) [10Rosenstein NE Perkins BA Stephens DS Popovic T Hughes JM Meningococcal disease.N Engl J Med. 2001; 344: 1378-1388Crossref PubMed Scopus (998) Google Scholar,11McGee ZA Kaiser AB Acute meningitis.in: Mandel GL Douglas RG Bennett JE Principles and practice of infectious diseases. Wiley, New York1985: 561-573Google Scholar]. Intravenous chloramphenicol 100 mg/kg per day, up to 4 mg/day, may be used in penicillin-allergic patients [11McGee ZA Kaiser AB Acute meningitis.in: Mandel GL Douglas RG Bennett JE Principles and practice of infectious diseases. Wiley, New York1985: 561-573Google Scholar]. The duration of parenteral therapy in healthy children without symptoms of systemic meningococcal infection has been not defined in the literature [1Barquet N Gasser I Domingo P Moraga FA Macaya A Elcuaz R Primary meningococcal conjunctivitis. Report of 21 patients and review.Rev Infect Dis. 1990; 12: 838-847Crossref PubMed Scopus (61) Google Scholar, 2Andersen J Lind I Characterization of Neisseria meningitidis isolates and clinical features of meningococcal conjunctivitis in ten patients.Eur J Clin Microbiol Infect Dis. 1994; 13: 388-393Crossref PubMed Scopus (14) Google Scholar, 3Moraga Llop FA Barquet Esteve N Domingo Pedrol P Gallart Catala A Primary meningococcal conjunctivitis: implications beyond the conjunctiva.Med Clin (Barc). 1996; 107: 130-132PubMed Google Scholar,5Wald ER Conjunctivitis in infants and children.Pediatr Infect Dis J. 1997; 16: S17-S20Crossref PubMed Scopus (24) Google Scholar,6Syed NA Hyndiuk RA Infectious conjunctivitis.Infect Dis Clin North Am. 1992; 6: 789-805PubMed Google Scholar]. The situation poses two questions: were healthy patients with PMC admitted into hospital only for parenteral therapy, and is a home-based oral therapy in conjuction with an observation program for healthy children with PMC after more than 5 days of evolution possible? Rifampin (600 mg twice daily for four doses in adults, children 10 mg/kg every 12 h for 2 days) is used in chemoprophylaxis for close contacts of patients, but is not recommended for pregnant women [10Rosenstein NE Perkins BA Stephens DS Popovic T Hughes JM Meningococcal disease.N Engl J Med. 2001; 344: 1378-1388Crossref PubMed Scopus (998) Google Scholar]. Other systemic antibiotics that effectively eliminate nasopharyngeal carriage of N. meningitidis include: ciprofloxacin, 500 mg once (not generally recommended for persons younger than 18 years of age or for pregnant or lactating women) [10Rosenstein NE Perkins BA Stephens DS Popovic T Hughes JM Meningococcal disease.N Engl J Med. 2001; 344: 1378-1388Crossref PubMed Scopus (998) Google Scholar]; intramuscular ceftriaxone, 125 mg once in children <15 years, and 250 mg in children ≥15 years and adults [10Rosenstein NE Perkins BA Stephens DS Popovic T Hughes JM Meningococcal disease.N Engl J Med. 2001; 344: 1378-1388Crossref PubMed Scopus (998) Google Scholar]; and azithromycin, 500 mg once [12Girgis N Sultan Y Frenck Jr, RW El-Gendy A Farid Z Mateczun A Azithromycin compared with rifampin for eradication of nasopharyngeal colonization by Neisseria meningitidis.Pediatr Infect Dis J. 1998; 17: 816-819Crossref PubMed Scopus (54) Google Scholar]. In conclusion, meningococcal conjunctivitis should be considered in healthy children with purulent conjunctivitis. Bacterial culture of purulent discharge from the eyes of patients with conjunctivitis is mandatory for diagnosis. The treatment of PMC should include combined topical and systemic therapy, in view of the potential for invasiveness of N. meningitidis, with appropriate chemoprophylaxis for close contacts of patients. However, there are many clinical situations in PMC that pose questions not resolved in the literature.