CONCISE COMMUNICATION

Primary meningococcal conjunctivitis

B. Orden1,, R. Martnez1, R. Millan1, M. Belloso1 and N. Perez2

1

Servicio de Microbiologia, Hospital Universitario Puerta de Hierro (C. E. Arguelles), Quintana 11, 28008
Madrid and 2Centro de Salud `Casa de Campo', Madrid, Spain

Tel: 34 1 541 78 20

Fax: 34 1 542 29 56

E-mail: monord@telefonica.net

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.
Accepted 16 April 2003

Clin Microbiol Infect 2003; 9: 12451247

Neisseria meningitidis is an uncommon cause of
acute bacterial conjunctivitis. However, its diagnosis has important therapeutic implications.
Acute conjunctivitis caused by N. meningitidis is
classied into primary (exogenous) and secondary
(endogenous) disease [1]. Primary meningococcal
conjunctivitis (PMC) can occur in two forms: invasive and non-invasive [2]. 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 [3]. In the latter, the conjunctivitis occurs as an isolated phenomenon [2].
Secondary meningococcal conjunctivitis occurs
as an unusual complication of systemic meningococcal disease [4].
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 [1].
We recently observed a patient with primary
unilateral meningococcal conjunctivitis. This case
reinforces the need for bacteriologic identication
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 exu-

date. 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 3537 8C 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% dened
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 identied as N. meningitidis by API NH (bio-Merieux,
Marcy-L'Etoile, France). This identication was
conrmed 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 ciprooxacin.
At 48 h, the eye culture was reported to the
pediatrician to have yielded N. meningitidis. The

2003 Copyright by the European Society of Clinical Microbiology and Infectious Diseases

1246 Clinical Microbiology and Infection, Volume 9 Number 12, December 2003
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 [5], but in children three
organisms are isolated more frequently from cases
of acute conjunctivitis: Haemophilus inuenzae,
Streptococcus pneumoniae, and adenoviruses [5,6].
Staphylococcus aureus is common at any age,
and can cause blepharitis and blepharoconjunctivitis [6].
Predisposing events for acquiring PMC include
ocular trauma [1] and close contact with a meningococcal carrier or another patient with systemic
meningococcal disease [1]. 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 [1].
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 [14,7,8].
The incidence of N. meningitidis conjunctivitis is
unknown. N. meningitidis accounted for 1.7% [3],
2% [7] and 2.4% [1] of the cases of bacterial conjunctivitis reported in the literature.
After PMC, ocular complications occurred in 0%
[2,3,7] and up to 15.5% [1] of the cases previously
reported. The most frequent were corneal ulcers
(69.2%); keratitis occurred in 15.4% [1], and subconjunctival hemorrhage or iritis was diagnosed in
7.7% [1].
Invasive meningococcal disease developed in
1029.4% of the patients with PMC [13], and
symptoms of systemic meningococcal disease

appeared at a mean interval of 41.3  30.5 h

(range 396 h) after appearance of the initial ocular
symptoms [1].
The treatment of PMC should include combined
topical and systemic therapy [1,2], in view of the
potential for invasiveness of N. meningitidis, with
appropriate chemoprophylaxis for close contacts
of the patients [2,8]. Forty-one per cent of the
patients who received only topical therapy, and
none of those who received systemic therapy,
developed invasive meningococcal disease [3],
and 93% of the patients with PMC and secondary
systemic disease had received only topical therapy
[1]. Systemic antibiotic therapy should be mandatory for all patients with PMC, although topical
antibiotics can be used as an adjunct to systemic
therapy [1]. 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 [9]) [10,11]. Intravenous chloramphenicol
100 mg/kg per day, up to 4 mg/day, may be used
in penicillin-allergic patients [11]. The duration of
parenteral therapy in healthy children without
symptoms of systemic meningococcal infection
has been not dened in the literature [13,5,6].
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 [10]. Other systemic antibiotics that effectively eliminate nasopharyngeal carriage of
N. meningitidis include: ciprooxacin, 500 mg once
(not generally recommended for persons younger
than 18 years of age or for pregnant or lactating
women) [10]; intramuscular ceftriaxone, 125 mg
once in children <15 years, and 250 mg in children
15 years and adults [10]; and azithromycin,
500 mg once [12].
In conclusion, meningococcal conjunctivitis
should be considered in healthy children with
purulent conjunctivitis. Bacterial culture of

2003 Copyright by the European Society of Clinical Microbiology and Infectious Diseases, CMI, 9, 12451247

Concise Communication 1247

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.
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2003 Copyright by the European Society of Clinical Microbiology and Infectious Diseases, CMI, 9, 12451247