Oman Journal of Ophthalmology

CLINICAL IMAGE
Year
: 2021  |  Volume : 14  |  Issue : 3  |  Page : 198--200

Ocular Neisseria gonorrhea in a patient on immune checkpoint inhibitors


Anuoluwapo Sopeyin1, Michael Minchul Park1, Renelle Pointdujour-Lim2,  
1 Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, CT, USA
2 Department of Ophthalmology and Visual Science, Yale School of Medicine; Yale Smilow Cancer Center, New Haven, CT, USA

Correspondence Address:
Dr. Renelle Pointdujour-Lim
35 Park Street, New Haven, CT 06510
USA

Abstract

Although immune checkpoint inhibitors have revolutionized the treatment of cancers, their role in the pathogenesis of chronic infections remains unclear. Here, we present the case of a patient on a cocktail of checkpoint inhibitors who presented with severe bilateral gonococcal conjunctivitis, orbital cellulitis and vitritis, without a history of genital infection.



How to cite this article:
Sopeyin A, Park MM, Pointdujour-Lim R. Ocular Neisseria gonorrhea in a patient on immune checkpoint inhibitors.Oman J Ophthalmol 2021;14:198-200


How to cite this URL:
Sopeyin A, Park MM, Pointdujour-Lim R. Ocular Neisseria gonorrhea in a patient on immune checkpoint inhibitors. Oman J Ophthalmol [serial online] 2021 [cited 2022 Aug 20 ];14:198-200
Available from: https://www.ojoonline.org/text.asp?2021/14/3/198/328608


Full Text



 Introduction



Immune checkpoint inhibitors (ICIs) are becoming widely used to treat various cancers. These medications upregulate the immune system and have been reported to cause ophthalmic immune-related adverse events including keratopathy, uveitis, inflammatory orbitopathy, and optic neuropathy.[1],[2] The interplay between ICIs and infections is not well established, and there is speculation that these medications may be protective against chronic infections.[3] Eron et al. showed that ICI use enhanced HIV-specific CD8+ T-cell responses in two of eight HIV-infected patients on antiretroviral therapy.[4] Davar et al. reported two cases of patients with chronic hepatitis C virus infections and melanoma whose viral load was unaffected by treatment with ICIs.[5] This case report illustrates an example of a patient on ICI therapy who develops a severe immunologic response to ocular Neisseria gonorrhoeae, and demonstrates the adverse effect that these medications may have in acute infections.

 Case Report



An 84-year-old man with metastatic cutaneous melanoma of the forearm treated with ICIs: nivolumab, cabiralizumab, and APX005M, developed worsening bilateral mucopurulent discharge over 2 days. He was prescribed ciprofloxacin eye drops in both eyes (OU) and later referred for worsening pain and blurred vision OU. The best-corrected vision was 20/400 right eye (OD) and 20/70 left eye (OS). The baseline vision was 20/70 OD due to a prior central retinal vein occlusion and 20/30 OS. Examination revealed periorbital erythema, eyelid edema, circumferential hemorrhagic chemosis, and copious mucopurulent discharge OU [Figure 1]. Extraocular motility was severely limited OU. Fundus examination revealed dense vitritis OD and was normal OS. B-scan ultrasound confirmed vitritis OD [Figure 2]. Magnetic resonance imaging orbits with contrast showed bilateral postseptal fat stranding consistent with postseptal cellulitis. Gram stain of the mucopurulent discharge showed Gram-negative diplococci. The patient was admitted and treated empirically for Neisseria gonorrhoeae with a 2-week course of intravenous ceftriaxone and systemic azithromycin. Later, cultures confirmed Neisseria gonorrhoeae [Figure 3]. Urine testing for chlamydia and gonorrhea was negative. Within 24 h of systemic treatment, vitritis OD resolved [Figure 4]. Six days after treatment, visual acuity returned to baseline, ocular motility was full, and chemosis completely resolved.{Figure 1}{Figure 2}{Figure 3}{Figure 4}

 Discussion



This patient presented developed bilateral conjunctivitis, bilateral orbital cellulitis, and vitritis as ocular manifestations of an acute Neisseria gonorrhoeae infection. To our knowledge, this is the first reported case of vitritis from Neisseria gonorrhoeae. Interestingly, the vitritis and orbital inflammation rapidly resolved with systemic antibiotic treatment without any intravitreal antibiotics, which suggests that the observed intraocular inflammation was an inflammatory reaction to the infection rather than to intraocular seeding of the infection. This case suggests that although ICI use might render some protective benefits in chronic infections,[3],[4] it can also lead to an exaggerated immune response in acute infections. Further studies are necessary to better understand the impact that ICIs have on the natural course of acute infections.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Acknowledgment

We would like to thank Yale New Haven Pathology Department.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Kim JM, Materin MA, Sznol M, Kluger HM, Weiss S, Chow J, et al. Ophthalmic immune-related adverse events of immunotherapy: A single-site case series. Ophthalmology 2019;126:1058-62.
2Dalvin LA, Shields CL, Orloff M, Sato T, Shields JA. Checkpoint inhibitor immune therapy: Systemic indications and ophthalmic side effects. Retina 2018;38:1063-78.
3Dyck L, Mills KH. Immune checkpoints and their inhibition in cancer and infectious diseases. Eur J Immunol 2017;47:765-79.
4Eron JJ, Gay C, Bosch R, Ritz J, Hataye JM, Hwang C, et al. Safety, immunologic and virologic activity of anti-PD-L1 in HIV-1 participants on ART. CROI [conference article]. Boston MA; 2016. Available from: https://www.croiconference.org/abstract/safety-immunologic-and-virologic-activity-anti-pd-l1-hiv-1-participants-art/. [Last accessed on 2020 Sep 01].
5Davar D, Wilson M, Pruckner C, Kirkwood JM. PD-1 Blockade in Advanced Melanoma in Patients with Hepatitis C and/or HIV. Case Rep Oncol Med. 2015;2015:737389. doi: 10.1155/2015/737389. Epub 2015 Sep 10. PMID: 26448890; PMCID: PMC4581502.