DJO - transmission by saliva Primary meningococcal … · 2016. 5. 25. · Alexander W.S. Dryden, BMBS , Mrinal Rana, MBBS, MRCOphth, and Pravin Pandey, MBChB, FRCOphth Author affiliations:

Case ReportPrimary meningococcal conjunctivitis: an unusual case oftransmission by salivaAlexander W.S. Dryden, BMBS, Mrinal Rana, MBBS, MRCOphth, and Pravin Pandey, MBChB,FRCOphthAuthor affiliations: Birmingham & Midland Eye Centre, Birmingham, United Kingdom

SummaryA 49-year-old diabetic man presented with a 2-day history of a painful right eye associated with a purulentdischarge. Prior to becoming symptomatic, he reported that someone spat at him, resulting in direct contactbetween the saliva and his affected eye. Gram stain revealed numerous leucocytes with Gram-negative dip-lococci, and culture yielded Neisseria meningitidis (serogroup C). There was no evidence of any systemicinfection, and blood cultures were negative for any growth. He was treated for primary meningococcal con-junctivitis (PMC) with intensive topical antibiotic eyedrops as well as systemic antibiotics. One week aftercommencing treatment he remained systemically well and his symptoms had fully resolved.

IntroductionNeisseria meningitidis is a rare cause of bacterial con-junctivitis. Previously reported cases of primary menin-gococcal conjunctivitis (PMC) suggest that children aremore frequently affected than adults, with 95% of casesoccurring in patients <25 years of age.1,2 AlthoughPMC is a rare cause of bacterial conjunctivitis, it has thepotential to develop into systemic and potentially life-threatening meningococcal infection in about 17.8% ofpatients.2 The current literature focuses on the impor-tance of administering both topical and systemic treat-ment to prevent PMC developing into systemic menin-gococcal infection. We report an unusual case of unilat-eral PMC, in which saliva may represent direct mode oftransmission for ocular infection.

Case ReportA 49-year-old man presented at Birmingham and Mid-land Eye Centre, United Kingdom, with a 2-day historyof a painful right eye associated with copious purulentdischarge. By the time he presented, he had difficultyopening his right eye because of swelling. He reportedthat approximately 10 days prior to the onset of symp-toms someone had spat directly into his right eye whiletrying to separate a fight. His past medical history inclu-ded hypercholesterolemia, vitamin B12 and D defi-ciency, and type 2 diabetes mellitus that was well con-

trolled on gliclazide and metformin. He had no historyof previous ocular problems and was not a contact lenswearer. Apart from the right eye conjunctivitis, his gen-eral health was good, with no history of fevers, photo-phobia, neck stiffness, or rash.

On examination, unaided Snellen visual acuity was 6/18in the right eye and 6/5 in the left eye. The left eyeappeared normal. Examination of the right eye revealeda closed eye, with purulent discharge, widespread che-mosis, subconjunctival hemorrhage, and hyperemia. Theright cornea had areas of subepithelial infiltration, stro-mal edema, and punctate epithelial erosions (Figure 1).Examination of the anterior chamber and posterior seg-ment was unremarkable. There was no evidence of sys-temic infection. A right conjunctival swab was sent forGram stain and culture before initial treatment was star-ted with topical chloramphenicol 0.5%. The Gram stainrevealed numerous leucocytes, with Gram-negative dip-lococci (Figure 2), and culture yielded Neisseria menin-gitidis (serogroup C). Peripheral blood cultures werenegative for growth. Following sensitivity results thepatient was admitted and treated with intensive topicalchloramphenicol 0.5% and ofloxacin 0.3% eye drops.He was also administered 3 doses of intravenous cef-triaxone.

Published January 07, 2016.doi:10.5693/djo.02.2015.09.001Correspondence: Dr. Alexander Dryden, Birmingham & Midland Eye Centre, Sandwell and West Birmingham Hospital NHS Trust, DudleyRoad, Birmingham, UK B18 7QH (email: [email protected]).

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By the third day of treatment, his symptoms had signifi-cantly improved, and he was discharged with topicalchloramphenicol 0.5% and a course of oral ciprofloxa-cin. One week later, the hyperemia, chemosis, and puru-

Figure 1. Right eye showing conjunctival injection with subepithe-lial corneal infiltrates and stromal haze. Image taken after 72 hoursof topical treatment.

Figure 2. Gram stain of conjunctival swab showing characteristicGram negative diplococci and polymorphs.

lent discharge had fully resolved (Figure 3). There wasevidence of peripheral stromal scarring but no activeinfiltrates. Visual acuity in the right eye had improved to20/16.7, and the patient remained well, with no evidenceof secondary infection.

DiscussionPrevious reports have demonstrated the importance oftreating PMC with both topical and systemic antibiotictreatment to prevent systemic meningococcal disease.2–4

Topical therapy alone is not sufficient to treat potentialnasopharyngeal carriage, and the risk of developinginvasive meningococcal disease is approximately 19times greater for those receiving topical treatment alonecompared to those also receiving systemic antibiotictreatment.2

However, there is little published literature reporting onpotential sources of PMC infection. Meningococcal con-junctivitis is a rare cause of conjunctivitis that is mostcommonly associated with invasive meningococcal dis-ease and rarely occurs in isolation. The present case isunusual because there is a very strong history to suggestthat the mode of transmission in this case was fromdirect ocular contact with saliva. To our knowledge,PMC infection through direct contact with saliva hasbeen reported only once before, in a nondiabetic individ-ual.5 The human pharyngeal mucosa is commonlycolonized with Neisseria meningitidis, and asympto-matic carriage is common, with a carriage prevalence ofup to 35% in some populations.6–8 The pathogenesis ofmeningococcal disease is not fully understood; itremains unclear as to why this commensal bacterium

Figure 3. Completely resolved infection with no signs of conjunc-tival congestion or corneal infiltrates.

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can colonize the nasopharynx of a large proportion ofthe population without any ill effects but cause poten-tially life-threatening invasive disease in a very smallminority. While the exact incidence of PMC is notknown, it is thought to be <2% of all cases of conjuncti-vitis, despite the high prevalence of meningococcal car-riage.9

Patients with diabetes are at increased risk of commoninfections.10 Further studies must be conducted to inves-tigate this subject, but it could be that our patient wasmore susceptible to developing PMC because he wasdiabetic. We cannot know for certain whether our patientwas colonized with Neisseria meningitidis prior to hisPMC infection or whether the meningococcal infectionwas transmitted by direct contact with saliva. Unfortu-nately, a throat culture from the individual who spat inthe patient’s eye could not be performed because hisidentity was unknown. This would have been helpful inconfirming the mode of transmission by establishingwhether the serogroup of Neisseria meningitidis was thesame as that cultured from the affected eye. A studyconducted by Orr et al8 found the prevalence of menin-gococcal carriage in saliva to be extremely low (0.4%)compared to carriage prevalence in the nasopharynx(32%) or tonsils (19%). They suggested that that lowlevels of salivary contact are unlikely to transmit menin-gococci. It is noteworthy that saliva from spitting islikely to contain not only saliva but also nasopharyngealsecretions, which Orr et al8 have shown to have a muchhigher prevalence of meningococcal carriage than puresaliva. While it is possible that our patient may havealready been an asymptomatic carrier of Neisseria men-ingitidis and developed a spontaneous PMC, the historyin this case suggests that the mode of transmission wasfrom direct ocular contact with saliva.

To our knowledge, there is only one previously reportedcase in the literature of PMC transmitted by saliva, withthis case being the first reported in a diabetic patient. Itmay be that individuals with diabetes have a relativelyhigher chance of developing PMC infections.

PMC can be difficult for clinicians to distinguish fromother forms of conjunctivitis because the clinical picturecan be very similar to more common conjunctival infec-tions.11 Early diagnosis of PMC and timely treatment isessential to reduce ocular complications and minimizethe risk of invasive systemic meningococcal disease.Once confirmed by Gram stain and culture, it is impor-

tant that treatment includes both focused topical and sys-temic antibiotics in order to treat nasopharyngeal coloni-zation as well as ocular disease.

Literature SearchThe authors searched the PubMed database in January2015, without language restriction, using the followingsearch terms: meningococcal conjunctivitis, Neisseriameningitidis, saliva AND transmission, bacterial con-junctivitis.

Acknowledgments

The authors thank the Medical Illustration Department atSandwell & West Birmingham Hospitals NHS Trust forFigures 2 and 3.

References1. Anderson J, Lind I. Characterization of Neisseria meningitidis iso-

lates and clinical features of meningococcal conjunctivitis in tenpatients. Eur J clinical Microbiol Infect Dis 1994 May;13:388-93.

2. Barquet N, Gasser I, Domingo P, Moraga FA, Macaya A, Elcuaz R.Primary meningococcal conjunctivitis: report of 21 patients andreview. Rev Infect Dis 1990;12:838-47.

3. Stansfield RE, Masterton RG, Dale BAS, Fallon RJ. Primary menin-gococcal conjunctivitis and the need for prophylaxis in close con-tacts. J Infect 1994;29:211-4.

4. Hagelskjaer LH, Schonheyder HC, Blichfeld LP. Primary meningo-coccal conjunctivitis—more than meets the eye! Acta Paediatr1993;82:979-80.

5. Holdsworth, Jackson H, Kaczmarski E. Meningococcal infectionfrom saliva. Lancet 1996;348:1443.

6. European Centre for Disease Prevention and Control. Public healthmanagement of sporadic cases of invasive meningococcal diseaseand their contacts. Stockholm: ECDC; 2010. http://www.ecdc.europa.eu/en/publications/Publications/1010_GUI_Meningococcal_guidance.pdf. Accessed October 29,2014

7. Cartwright KAV, Stuart JM, Jones DM, Noah ND. The Stonehousesurvey: nasopharyngeal carriage of meningococci and Neisseria lac-tamica. Epidemiol Infect 1987;99:591-601.

8. Orr HJ, Gray SJ, Macdonald M, Stuart JM. Saliva and meningococ-cal transmission. Emerg Infect Dis October;2003 9:1314-5.

9. Neoh C, Agious-Fernandez A, Kaye SB, Molyneux EM, Hart CA.Primary meningococcal conjunctivitis in children. Br J Clin Pract1994;48:27-8.

10. Muller LM, Gorter KJ, Hak E, et al. Increased risk of commoninfections in patients with type 1 and type 2 diabetes mellitus. ClinInfect Dis 2005;41:281-8.

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DJO - transmission by saliva Primary meningococcal … · 2016. 5. 25. · Alexander W.S. Dryden, BMBS , Mrinal Rana, MBBS, MRCOphth, and Pravin Pandey, MBChB, FRCOphth Author affiliations: