계명의대학술지제 37 권 2 호 Keimyung Med J Vol. 37, No. 2, December, 성인남성에서단안에발생한임균성결막염 1 례 이유현 류남희 1 전종화 계명대학교의과대학안과학교실, 진단검사의학교실 1 A Case of Monocula

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1 계명의대학술지제 37 권 2 호 Keimyung Med J Vol. 37, No. 2, December, 성인남성에서단안에발생한임균성결막염 1 례 이유현 류남희 1 전종화 계명대학교의과대학안과학교실, 진단검사의학교실 1 A Case of Monocular Gonococcal Conjunctivitis in an Adult Male You Hyun Lee, M.D., Nam Hee Ryoo 1, M.D., Jong Hwa Jun, M.D. Department of Ophthalmology, Laboratory Medicine 1, Keimyung University School of Medicine, Daegu, Korea Received: September 30, 2018 Revised: November 20, 2018 Accepted: December 28, 2018 Corresponding Author: Jong Hwa Jun, M.D. Department of Ophthalmology, Keimyung University School of Medicine, 56 Dalseong-ro, Jung-gu, Daegu 41931, Korea Tel: junjonghwa@gmail.com The authors report no conflict of interest in this work. Copyright Keimyung University School of Medicine 2018 Gonococcal conjunctivitis is rare in adults and, if not treated properly, can cause corneal perforation. Gonococcal conjunctivitis typically presents with a severe mucopurulent discharge, similar to that associated with viral conjunctivitis. Here, we describe a case of monocular gonococcal conjunctivitis, including its clinical characteristics and slit-lamp images, which was initially misdiagnosed as epidemic conjunctivitis. A 20-year-old man was referred to our hospital with no improvement in monocular infection and purulent ocular discharge after 2-wk treatment using antibiotic and 0.1% fluorometholone eye drops at the local ophthalmic clinic. Initially, 0.5% loteprednol eye drops were used since we suspected viral conjunctivitis. Following this treatment, conjunctival infection worsened and a yellow-white ocular discharge covered the conjunctiva and cornea surface. Additional history taking revealed that the patient had sexual contact with a prostitute 1 wk prior to symptom presentation and, after the encounter, he took antibiotics for genital discharge at the local urology clinic, but self-discontinued treatment. A Gram staining showed gram-negative diplococci and culture of collected ocular discharge from the palpebral conjunctiva revealed growth of Neisseria gonorrhoeae, confirming gonococcal conjunctivitis. Following this, the patient was systemically treated with 3rd generation cephalosporin antibiotics. After 3-d treatment, conjunctival infection and purulent ocular discharge had significantly improved. When clinical symptoms are aggravated following steroid eye drop treatment for suspected monocular viral conjunctivitis, gonococcal conjunctivitis must be considered as a differential diagnosis Keywords: Cephalosporin, Gonococcal conjunctivitis, Neisseria gonorrheae

2 102 계명의대학술지제 37 권 2 호 2018 서론임균에의한결막염은신생아이외에는드물다고알려져있으나남성에서는감염된요로생식계분비물의자가접종, 여성에서는콘돔을사용하지않은구강성교의증가로인해성인에서의발병률이증가하고있다 [1-3]. 임균성결막염은 1,000안당 안의유병률을가지고있으며젊은남성이여성보다더흔한것으로알려져있다 [4,5]. 임상양상은양안또는단안에서초급성으로발생하는심한결막충혈과부종, 많은양의화농성분비물이특징적인소견이며이외에도안구불편감또는통증, 귓바퀴앞임파선염, 안검부종, 각막상피및실질의염증을관찰할수있으며치료가늦어지면각막천공으로영구적시력손실을초래할수있어빠른진단과치료가중요하다 [6-8]. 임균성결막염은그람염색과세균배양검사에서 90% 이상진단되며치료에대해서는여러보고가있지만, 점안항생제에대해서는효과가불분명하며 1 g ceftriaxone의전신적투여가중요하다는데의견이일치한다 [9-11]. 국내외에서임균성각결막염을 3세대 cephalosporin을전신적으로사용하여효과적으로치료한보고가있으나세극등현미경사진을함께첨부한경우는드물며있더라도사진해상도가좋지않아진료에참고하기에어려움이있다 [12,13]. 이에저자들은 20세성인남자환자에서초기에유행성결막염으로오진한단안에발생한임균성결막염 1례를진단하고치료한경험을그임상양상및세극등현미경사진과함께보고하고자한다. 증례 20세남자환자가 3주전부터지속된우안의안검부종및결막충혈, 부종, 화농성분비물및간헐적인통증을주소로내원하였다. 환자는증상발현후개인안과에서바이러스결막염의심하에 0.5% 레보플록사신 (Cravit R, Santen pharmaceutical Co., Osaka, Japan), 0.1% 플루오로메토론점안액 (Ocumetholone R, Samil, Seoul, Korea) 을세시간마다점안하였고오플록사신안연고 (Ocuflox R, Samil, Seoul, Korea) 를자기전에점안하여 2주동안치료하였으나호전을보이지않아 본원으로전원되었다. 본원내원당시세극등현미경검사에서우안상하안검의부종, 결막의심한충혈및부종이있었고중등도의분비물이관찰되었다. 반면좌안에는특별한이상이관찰되지않았다. 우안의나안시력은 20/50, 교정시력은 20/25이었다. 초기진료시아데노바이러스에의한결막염을우선적으로고려하여우안주위의부종및염증을감소시킬목적으로 0.1% 플루오로메토론점안액을 0.5% 로테프레드놀점안액 (Lotemax R, Bausch & Lomb, Tampa, FL, USA) 로바꾸고하루 5회점안하도록하고경과관찰하였다. 4일뒤시행한세극등현미경검사에서우안의결막충혈은급격히악화되었으며화농성분비물의양또한증가하여상하안검결막과, 구결막및각막을모두뒤덮을정도로극히심해진양상이관찰되었다 (Fig. 1). 좌안에증상및징후가없는점과추가적인자세한병력청취에서최초안증상발현일주일전유흥업소에종사하는여성과성적접촉을하였음을확인하였다. 또한성적접촉 3~4일후배뇨통으로요도염의심하에개인비뇨기과의원에서치료도중증상이약간호전되자자의적으로치료를중단한적이있었다는것을확인하였다. 당시소변검사를시행하였으나정확한진단은환자가기억하지못하였다. 이에세균성결막염을의심하여무균면봉으로우안화농성분비물을채취해슬라이드에도말하여그람염색 (Gram staining) 을시행하였고세균배양검사를위해검체를혈액한천배지 (blood agar plate) 에접종하였다. 그람염색에서는 intra- and extracelluar 그람음성쌍구균이관찰되었으며세균배양검사에서는 Neisseria gonorrheae가동정되어임균성결막염을확진하였다 (Fig. 2). 즉각적으로로테프레드놀점안제의사용을중지하였고치료를위해감염내과에협진의뢰하여 1 g ceftriaxone (Rocephin R, Roche Diagnostics Corp., USA) 을 1회정주하였으며 3세대 cephalosporin계경구항생제 (Suprax R, Dong-A Pharmaceutical Co., Seoul, Korea) 를하루에두번씩 5일간복용하도록하였다. 치료시작후 3일째우안나안시력은 20/20으로회복되었으며세극등현미경검사에서결막충혈과황백색의화농성분비물은급격히호전되었다 (Fig. 3). 이후환자는경과관찰중임의로내원을중단하였다.

성인에서발생한임균성결막염 103 A B C D Fig. 1. Photographs at 4th day after the 0.5% loteprednol eye drop was used. (A) Cornea surface covered with yellow-white thick purulent ocular discharge (arrow).

3 성인에서발생한임균성결막염 103 A B C D Fig. 1. Photographs at 4th day after the 0.5% loteprednol eye drop was used. (A) Cornea surface covered with yellow-white thick purulent ocular discharge (arrow). (B-D) Severe chemosis and conjunctival injection with yellow-white purulent ocular discharge at bulbar conjunctiva (B, arrow head), and palpebral conjunctiva (D, arrow head). 고찰임균에의한안감염은일반적으로안검부종, 화농성분비물, 충혈, 결막부종등의증상을동반하며적절히치료하지않으면감염이결막에서각막으로이동하여주변부각막궤양을일으키며빠르게진행하여심하면각막궤양및천공을유발할수있다 [6,14]. 임균의잠복기간은 3일에서 19일까지다양하고성적접촉병력의누락으로임균성결막염진단이지연되는경우가많다 [15]. 본증례에서도 7일간의잠복기간이있었으며성적접촉과거력이뒤늦게확인되어진단이늦어졌다. McAnena 등 [4] 은성인에서발생하는임균성결막염은남성과단안에서호발한다하였는데본증례에서도환자는 20세남자였으며우안에서만병변이관찰되었다. 또한, 소아에서와는다르게성인에서발생하는임균성 결막염의감염경로는대부분감염된소변이나생식기분비물에접촉하거나오염된손에의한균의직접접종에의한것으로알려져있는데환자의경우도증상발현 1주일전성적접촉및이후요도염증상의발현이있어이에의한발생을의심할수있었다 [16]. 본증례의경우안증상과배뇨통이동반되어비뇨기과에서요도염으로치료를받은적이있었지만 Peters 등 [11] 은요도염에치료되는항생제의농도가안구병변을치료하기에는부족하다고보고하였으며환자가치료를자의로중단하여안증상은지속되었던것으로여겨지며전신항생제의사용에의해플루오로메토론등의스테로이드점안제의사용중에도각막침범등의양상은거의없었던것으로생각된다. 다만, 환자가비뇨기과치료를자의로중단하여요도염및결막염의완전한치료가이루어지지않고본원내원당시초기 0.5% 로테프레드놀점안액을사용하고안구

diplococcic (x1000, oil immersion). A B Fig. 3. Photographs at 3rd day after the 3rd-generation cephalosporin antibiotic was used systemically.

4 104 계명의대학술지제 37 권 2 호 2018 Fig. 2. Gram staining of the yellow-white purulent ocular discharge smear showed many polymorphonuclear cells with intra- (arrow) and extracelluar (arrow head) gram negative reniform diplococcic (x1000, oil immersion). A B Fig. 3. Photographs at 3rd day after the 3rd-generation cephalosporin antibiotic was used systemically. (A) Disappearance of yellow-white purulent ocular discharge on cornea. (B) Dramatically improved yellow-white purulent ocular discharge in lower palpebral conjunctiva. 병변이악화된것은적절한항생제치료가이루어지기전에점안스테로이드제를사용하여잠재적으로질병의경과를연장함과동시에세균의감염력을증가시켰기때문으로생각된다. 임균성결막염의효과적인치료에대한연구중국외에서는 Haimovici 등 [9] 이 ceftriaxone을 1회근주하여 13명의환자를효과적으로치료하였고국내에서는 Kim 등 [12] 이 ceftriaxone을하루 1회 5일동안근주함과동시에 3세대 cephalosporin 계점안제를사용하여 1명의환자를성공적으로치료한보고가있다. 본증례에서는 ceftriaxone (Rocephin R ) 을 1회근주하고 5일간의경구약복용으로임상증상의급격한호전을경험하였는데이는임균성결막염의치료에는전신적항생제투여가중요함을보여준다.

5 성인에서발생한임균성결막염 105 임균성결막염은치료시작후 12시간이내에화농성분비물이호전되고 6시간이내에세균배양검사에서 Neisseria gonorrheae의음성이확인된다고알려져있다 [17]. 본증례에서는치료후세균배양검사를시행하지않았지만, 치료시작후 3일째화농성분비물이급속히호전됨을확인하였다. 요약결론적으로젊은성인남성에서단안에아데노바이러스에의한결막염을의심하여점안스테로이드제를사용후임상양상이악화되어황백색의화농성분비물이결막및각막에서관찰되고심한충혈과결막부종이관찰된다면임균성결막염을감별진단의하나로고려하여야한다. 참고문헌 1. Quirke M, Cullinane A. Recent trends in chlamydial and gonococcal conjunctivitis among neonates and adults in an Irish hospital. Int J Infect Dis 2008;12: Lee JS, Choi HY, Lee JE, Lee SH, Oum BS. Gonococcal keratoconjunctivitis in adults. Eye (Lond) 2002;16: Copen CE, Chandra A, Martinez G. Prevalence and timing of oral sex with opposite-sex partners among females and males aged years: United States, Natl Health Stat Report 2012;16: McAnena L, Knowles SJ, Curry A, Cassidy L. Prevalence of gonococcal conjunctivitis in adults and neonates. Eye (Lond) 2015;29: Lahra MM. Australian Gonococcal Surveillance Programme annual report, Commun Dis Intell Q Rep 2013;37:E Wan WL, Farkas GC, May WN, Robin JB. The clinical characteristics and course of adult gonococcal conjunctivitis. Am J Ophthalmol 1986;102: Schwab L, Tizazu T. Destructive epidemic Neisseria gonorrheae keratoconjunctivitis in African adults. Br J Ophthalmol 1985;69: Kawashima M, Kawakita T, Den S, Tomita M, Shimazaki J. Surgical management of corneal perforation secondary to gonococcal keratoconjunctivitis. Eye (Lond) 2009;23: Haimovici R, Roussel TJ. Treatment of gonococcal conjunctivitis with single-dose intramuscular ceftriaxone. Am J Ophthalmol 1989;107: Azari AA, Barney NP. Conjunctivitis: a systematic review of diagnosis and treatment. JAMA 2013;310: Peters RP, Verweij SP, McIntyre JA, Schaftenaar E. Gonococcal Conjunctivitis Despite Successful Treatment of Male Urethritis Syndrome. Sex Transm Dis 2016;43: Kim HK, Lee JS, Lee JR. Gonococcal Keratoconjunctivitis in Adult. J Korean Ophthalmol Soc 2002;43: Bodurtha Smith AJ, Holzman SB, Manesh RS, Perl TM. Gonococcal Conjunctivitis: A Case Report of an Unusual Mode of Transmission. J Pediatr Adolesc Gynecol 2017;30: McElnea E, Stapleton P, Khan S, Stokes J, Higgins G. Challenges in the management of Neisseria gonorrhoeae keratitis. Int Ophthalmol 2015;35: Bruins SC, Tight RR. Laboratory-acquired gonococcal conjunctivitis. JAMA 1979;241: Diena BB, Wallace R, Ashton FE, Johnson W, Platenaude B. Gonococcal conjunctivitis: accidental infection. Can Med Assoc J 1976;115:609, Fraunfelder FT, Fraunfelder FW, Roy FH. Roy and Fraunfelder's current ocular therapy. Philadelphia, Pa: Elsevier Saunders; 2008.

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A 617 Special Issue Diabetic Retinopathy Won Ki Lee, M.D. Department of Ophthalmology The Catholic University of Korea College of Medicine Kangnam St. Mary s Hospital E mail : wklee@catholic.ac.kr Abstract R