Gonococcal orbital cellulitis in an adolescent: A diagnostic challenge in determining the transmission pathway

Abstract

Introduction

Neisseria gonorrhoeae is a well-known cause of conjunctivitis but an exceptionally rare cause of preseptal or orbital cellulitis. While sexual contact is the main mode of transmission, non-sexual routes have been documented, posing a diagnostic challenge. This article reports a case of N. gonorrhoeae orbital cellulitis with an associated abscess in an adolescent female who denied sexual activity and reviews the existing literature on this unusual presentation.

Methods

We present the case of a 16-year-old female who was admitted for evaluation of unilateral vision loss and proptosis. Additionally, a literature search of multiple core databases was performed for publications between 1975 and 2025 to identify all documented cases of gonococcal preseptal and orbital cellulitis.

Results

A 16-year-old patient was diagnosed with orbital cellulitis and a pre-septal abscess. Gram stain of the purulent eye discharge revealed Gram-negative diplococci, and cultures subsequently confirmed N. gonorrhoeae isolation. The patient responded favorably to treatment with ceftriaxone and doxycycline. Literature review was able to identify only seven documented cases of N. gonorrhoeae-associated orbital cellulitis and nine cases of preseptal cellulitis reported over the last 50 years, highlighting the importance of this clinical entity.

Conclusions

This case expands the known clinical spectrum of atypical gonococcal infections. N. gonorrhoeae should be considered in the differential diagnosis of orbital cellulitis in adolescent patients, even when a history of sexual activity is denied. This report underscores the importance of considering alternative transmission routes and utilizing appropriate microbiological diagnostics to ensure timely and effective treatment.