Medscape is available in 5 Language Editions – Choose your Edition here.


Gonococcal Arthritis Clinical Presentation

  • Author: Rachel Robbins, MD; Chief Editor: Herbert S Diamond, MD  more...
Updated: Aug 12, 2016


The clinical presentation of disseminated gonococcal infection (DGI) is typically divided into a bacteremic form and a septic arthritis form. Approximately 60% of patients present with symptoms consistent with the bacteremic form, and the remaining 40% present with symptoms of more localized infection. Although each form presents with its own symptom complex, the overlap can be considerable. The time from initial infection to initial manifestations of disease ranges from 1 day to 3 months.[1]

Bacteremic form

In the bacteremic form (arthritis-dermatitis syndrome), symptoms are typically present 3-5 days before diagnosis.[9]

Migratory arthralgias are the most common presenting symptom in persons with DGI and are usually polyarticular. The arthralgias are typically asymmetric and tend to involve the upper extremities more than the lower extremities. The wrist, elbows, ankles, and knees are most commonly affected. Symptoms resolve spontaneously in 30-40% of cases or evolve into a septic arthritis in 1 or several joints.

Pain may also be due to tenosynovitis. The tenosynovitis of DGI is asymmetric and most commonly occurs over the dorsum of the wrist and hand, as well as over the metacarpophalangeal joints, ankles, and knees. Diffuse involvement of fingers can result in dactylitis.[1]

The rash associated with the bacteremic form of DGI may be overlooked by patients because it is painless and nonpruritic and consists of small papular, pustular, or vesicular lesions.

Nonspecific constitutional symptoms may include myalgias, fever, and malaise.

Septic arthritis form

Joint symptoms begin within days to weeks of gonococcal infection.[9] Patients may experience pain, redness, and swelling in 1 joint (or sometimes multiple joints), most commonly in a knee, wrist, ankle, or elbow.[1]


Physical Examination

Bacteremic form

The bacteremic form of gonococcal arthritis comprises the classic triad of migratory polyarthritis, tenosynovitis, and dermatitis.[9] Migratory arthritis has an asymmetric distribution, most commonly affecting wrists, ankles, and elbows. About 70% of patients have 1-3 joints with clear inflammatory signs after just a few days. Symmetric polyarthritis is less common but may occur in approximately 10% of patients.

Tenosynovitis is asymmetric, usually affecting the dorsum of wrists, hands, and ankles. Tenosynovitis of the fingers may result in dactylitis.

Dermatitis occurs in 40-70% of patients and typically involves the extremities. Lesions are usually tiny maculopapular, pustular, or vesicular lesions on an erythematous base. The center may become necrotic or hemorrhagic. Despite their appearance, these lesions are painless and nonpruritic. They tend to disappear within a few days after treatment is initiated. Usually, 4-50 lesions are reported. Rarely, the lesions may resemble erythema nodosum or erythema multiforme.

Fever rarely involves a temperature higher than 39°C.

Other presentations of DGI include the following, which now occur in only 1-3% of cases[1, 10] :

  • Fitz-Hugh-Curtis syndrome (gonococcal perihepatitis)
  • Sepsis with Waterhouse-Friderichsen syndrome
  • Gonococcal endocarditis (rare in the antibiotic era)
  • Gonococcal meningitis (very rare in the antibiotic era)
  • Paravertebral abscess

Septic arthritis form

Septic arthritis is characterized by acute arthritis with signs of joint effusion, warmth, tenderness, decreased range of motion, and marked erythema. It most commonly involves the wrists, hands, knees, and elbows. Chronic arthritis with joint destruction is rare when appropriate antibiotic therapy is provided.



As a rule, complications of gonococcal arthritis are rare. When they do occur, they may include any of the following:

  • Permanent joint damage
  • Pericarditis
  • Perihepatitis
  • Pyomyositis
  • Glomerulonephritis
  • Meningitis
  • Endocarditis
  • Osteomyelitis
Contributor Information and Disclosures

Rachel Robbins, MD Internist and Chief of Medical Residents, Walter Reed National Military Medical Center; Assistant Professor of Medicine, Uniformed Services University

Rachel Robbins, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.


Michael P Keith, MD, FACP, FACR Chief of Rheumatology, Walter Reed National Military Medical Center; Associate Professor of Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

Michael P Keith, MD, FACP, FACR is a member of the following medical societies: American College of Physicians, American College of Rheumatology, Clinical Immunology Society

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.


Lawrence H Brent, MD Associate Professor of Medicine, Jefferson Medical College of Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center

Lawrence H Brent, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Physicians, and American College of Rheumatology

Disclosure: Genentech Honoraria Speaking and teaching; Genentech Grant/research funds Other; Amgen Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Abbott Immunology Honoraria Speaking and teaching; Takeda Honoraria Speaking and teaching; UCB Speaking and teaching; Omnicare Consulting fee Consulting; Centocor Consulting fee Consulting

Timothy M Straight, MD Instructor, Department of Medicine, Uniformed Services University School of Medicine

Timothy M Straight, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

  1. Dalla Vestra M, Rettore C, Sartore P, Velo E, Sasset L, Chiesa G, et al. Acute septic arthritis: remember gonorrhea. Rheumatol Int. 2008 Nov. 29(1):81-5. [Medline].

  2. Bardin T. Gonococcal arthritis. Best Pract Res Clin Rheumatol. 2003 Apr. 17(2):201-8. [Medline].

  3. Rice PA. Gonococcal arthritis (disseminated gonococcal infection). Infect Dis Clin North Am. 2005 Dec. 19(4):853-61. [Medline].

  4. Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2014. Atlanta, GA: U.S.Department of Health and Human Services; November 2015. [Full Text].

  5. Roth A, Mattheis C, Muenzner P, Unemo M, Hauck CR. Innate recognition by neutrophil granulocytes differs between Neisseria gonorrhoeae strains causing local or disseminating infections. Infect Immun. 2013 Jul. 81(7):2358-70. [Medline].

  6. World Health Organization Fact Sheet Number 110. Available at December 2015; Accessed: July 26, 2016.

  7. Belkacem A, Caumes E, Ouanich J, Jarlier V, Dellion S, Cazenave B, et al. Changing patterns of disseminated gonococcal infection in France: cross-sectional data 2009-2011. Sex Transm Infect. 2013 Dec. 89 (8):613-5. [Medline].

  8. Tuttle CS, Van Dantzig T, Brady S, Ward J, Maguire G. The epidemiology of gonococcal arthritis in an Indigenous Australian population. Sex Transm Infect. 2015 Mar 19. [Medline].

  9. Marker-Hermann E. Septic arthritis, osteomyelitis, gonococcal and syphilitic arthritis. Hochberg MC, Silman AJ, Smolen JS, Weinblatt ME, Weisman MH. Rheumatology. 4th ed. Philadelphia, PA: Mosby Elsevier; 2008. 1013-28.

  10. Low SY, Ong CW, Hsueh PR, Tambyah PA, Yeo TT. Neisseria gonorrhoeae paravertebral abscess. J Neurosurg Spine. 2012 Jul. 17(1):93-7. [Medline].

  11. Davis BT, Pasternack MS. Case records of the Massachusetts General Hospital. Case 19-2007 - a 19-year-old college student with fever and joint pain. N Engl J Med. 2007 Jun 21. 356(25):2631-7. [Medline].

  12. Liebling MR, Arkfeld DG, Michelini GA, Nishio MJ, Eng BJ, Jin T, et al. Identification of Neisseria gonorrhoeae in synovial fluid using the polymerase chain reaction. Arthritis Rheum. 1994 May. 37(5):702-9. [Medline].

  13. Read P, Abbott R, Pantelidis P, Peters BS, White JA. Disseminated gonococcal infection in a homosexual man diagnosed by nucleic acid amplification testing from a skin lesion swab. Sex Transm Infect. 2008 Oct. 84(5):348-9. [Medline].

  14. Kimmitt PT, Kirby A, Perera N, Nicholson KG, Schober PC, Rajakumar K, et al. Identification of Neisseria gonorrhoeae as the causative agent in a case of culture-negative dermatitis-arthritis syndrome using real-time PCR. J Travel Med. 2008 Sep-Oct. 15(5):369-71. [Medline].

  15. [Guideline] Workowski KA, Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5. 64 (RR-03):1-137. [Medline]. [Full Text].

  16. Centers for Disease Control and Prevention. Notice to readers: discontinuation of spectinomycin. MMWR. 2006. 55:370.

  17. Centers for Disease Control and Prevention. Update to CDC’s Sexually Transmitted Diseases Treatment Guidelines 2006: Fluoroquinolones no longer recommended for treatment of gonococcal infections. Available at Accessed: April 13, 2014.

  18. Centers for Disease Control and Prevention (CDC). Update to CDC's Sexually Transmitted Diseases Treatment Guidelines, 2010: Oral Cephalosporins No Longer a Recommended Treatment for Gonococcal Infections. MMWR Morb Mortal Wkly Rep. 2012 Aug 10. 61:590-4. [Medline].

  19. Kirkcaldy RD, Harvey A, Papp JR, Del Rio C, Soge OO, Holmes KK, et al. Neisseria gonorrhoeae Antimicrobial Susceptibility Surveillance - The Gonococcal Isolate Surveillance Project, 27 Sites, United States, 2014. MMWR Surveill Summ. 2016 Jul 15. 65 (7):1-19. [Medline]. [Full Text].

synovial joint
The lesion on this patient's heel was due to the systemic dissemination of the N. gonorrhoeae bacteria.
The foot of this patient is swollen due to gonococcal arthritis.
This patient presented with cutaneous foot lesions that were diagnosed as a disseminated gonococcal infection.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.