Background Preseptal cellulitis is an infection of the anterior portion of the eyelid and can present with chemosis and eye pain. Preseptal cellulitis and conjunctivitis is a rare, sight threatening infection, is less common in adults, and is usually caused by Streptococcus or Staphylococcus species. Neisseria gonorrhea rarely causes preseptal cellulitis with only four cases previously described.

Methods We describe a case of preseptal cellulitis caused by Neisseria gonorrhea.

Results: Case A 43-year-old woman presented with progressive pain and swelling of her left eye, a low-grade fever and dysuria. On exam, she was afebrile, had significant mucopurulent discharge, eyelid erythema, and a normal cornea. A CT scan of the orbit showed left periorbital preseptal soft tissue swelling. A nucleic acid amplification test (NAAT) for Neisseria gonorrhea was positive in both the left eye swab and a urine specimen. Bacterial cultures from swabs from the eye were also positive for Neisseria gonorrhea. She initially received intravenous (IV) cefepime, vancomycin, piperacillin/tazobactam that were subsequently changed to ceftriaxone, daptomycin and one dose of oral azithromycin. She completed a course of IV ceftriaxone daily for 4 days and 6 additional days of oral cefixime, tobramycin eye drops, and trimethoprim-sulfamethoxazole. She had significant clinical improvement within 3 days and her eye healed well.

Conclusion Clinicians must consider N. gonorrhea infection in patients presenting with acute, unilateral, mucopurulent conjunctivitis and preseptal cellulitis. Rapid diagnosis is critical and we demonstrate the utility of NAAT on an eye specimen. Contact isolation precautions are encouraged, as there is evidence of transmission through fomites and contaminated hands. Treatment data are limited, but we recommend at least 3 days of IV ceftriaxone in combination with azithromycin before transitioning to oral antibiotics based on susceptibilities. In the era of antibiotic resistant gonorrhea, clinicians must be vigilant to ensure appropriate antibiotic treatment of this severe eye infection.

Disclosure No significant relationships.