A 28-year-old woman presents with acute onset of bilateral conjunctival injection, mucopurulent discharge, and severe eye pain for 2 days. She reports recent unprotected sexual contact. On examination, both eyes show chemosis, lid swelling, and preauricular lymphadenopathy. Gram stain of the discharge reveals gram-negative diplococci. What is the most appropriate immediate management?

Explanation

## Diagnosis: Gonococcal Conjunctivitis **Key Point:** Gram-negative diplococci (Neisseria gonorrhoeae) causing acute bilateral conjunctivitis with mucopurulent discharge in a sexually active adult is gonococcal conjunctivitis until proven otherwise. **Clinical Pearl:** Gonococcal conjunctivitis is a medical emergency because of the risk of corneal perforation and blindness if untreated. The organism produces proteolytic enzymes that can rapidly destroy corneal tissue. ### Why Intravenous Ceftriaxone? Gonococcal conjunctivitis requires systemic therapy because: 1. **Resistance patterns**: Topical antibiotics alone achieve insufficient aqueous humor and systemic levels 2. **Organism virulence**: N. gonorrhoeae is highly invasive and can cause keratitis and corneal scarring within 24–48 hours 3. **Systemic involvement**: The infection often has urogenital involvement requiring systemic treatment ### Management Algorithm ```mermaid flowchart TD A[Acute conjunctivitis + Gram-negative diplococci]:::outcome --> B{Sexual history + Severity?}:::decision B -->|Severe, bilateral, mucopurulent| C[Gonococcal conjunctivitis suspected]:::urgent C --> D[IV Ceftriaxone 1g IM/IV Q12H]:::action D --> E[Topical erythromycin ointment QID]:::action E --> F[Systemic doxycycline 100mg BD for 7 days]:::action F --> G[Contact tracing + STI screening]:::action G --> H[Corneal healing achieved]:::outcome ``` ### Antibiotic Regimen | Agent | Dose | Route | Duration | Purpose | |-------|------|-------|----------|----------| | Ceftriaxone | 1 g | IM/IV | Q12H × 3 days | Systemic eradication | | Erythromycin | 0.5% ointment | Topical | QID | Local coverage + neonatal prophylaxis | | Doxycycline | 100 mg | Oral | BD × 7 days | Chlamydial co-infection coverage | **High-Yield:** Always assume concurrent Chlamydia trachomatis infection (30–50% of gonococcal cases); doxycycline covers both. **Warning:** Topical antibiotics alone are inadequate — they do not achieve sufficient aqueous humor levels and will result in treatment failure and corneal complications. ### Supportive Care - Frequent saline irrigation to remove discharge - Avoid eye patching (increases bacterial proliferation) - Daily ophthalmology review for corneal involvement - Partner notification and treatment [cite:Harrison 21e Ch 164]