Gonorrhea Differential Diagnoses

Updated: Jun 15, 2021
  • Author: Shahab Qureshi, MD, FACP; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
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Diagnostic Considerations

When evaluating a female patient with suspected gonococcal infection, also consider bacterial vaginosis, vaginitis, ectopic pregnancy, pregnancy, tubo-ovarian abscess, endometriosis, and mucopurulent cervicitis. In men, consider epididymitis, orchitis, and testicular torsion.

Other conditions that should be considered include the following:

  • Urinary tract infections
  • Pharyngitis; hepatitis
  • Herpes simplex urethritis
  • Rat-bite fever
  • Inflammatory and septic arthritis
  • Nongonococcal conjunctivitis, endocarditis, meningitis, and urethritis

Differential diagnosis of DGI

Other causes of arthritis and dermatitis may display a clinical picture similar to that of disseminated gonococcal infection (DGI), with some notable differences. Certain risk factors for disseminated infection should be kept in mind, such as acquired complement deficiencies (C5, C6, C7, C8), underlying systemic lupus erythematosus, pregnancy, and recent menstruation.

Reactive arthritis

Reactive arthritis is a human leukocyte antigen B27 (HLA-B27)–associated condition that predominantly occurs in young men and has the clinical triad of urethritis, conjunctivitis, and arthritis. However, the distribution of the arthritis is different, occurring predominantly in the joints of the axial skeleton. The clinical picture is less acute, occurring over the course of weeks rather than days and with less severe fever. This syndrome does not respond to antibiotic therapy, and it does not have the associated dermatitis that occurs in gonococcemia.

Nongonococcal septic arthritis

Nongonococcal septic arthritis can be caused by a variety of organisms, but it presents with an acute onset of joint swelling and pain. Culture of joint fluid commonly reveals organisms. This type of arthritis is a destructive form of arthritis that is usually monoarticular. It most frequently occurs in children and elderly persons. Immediate treatment with antibiotics is indicated.

Rheumatic fever

Rheumatic fever is a rare illness in the modern era and can present with high fever, rash, arthritis, and endocarditis. This condition follows a streptococcal infection and requires long, emergent intravenous (IV) antibiotic therapy for endocarditis; it also responds well to anti-inflammatory medications.


Syphilis, an STD that commonly occurs in sexually active young adults, can also produce a rash, symptoms of arthritis, and genital lesions. However, genital involvement is usually in the form of an ulcer and not urethritis, and the rash can involve the palms and the soles. Laboratory tests, including rapid plasma reagin (RPR) titers, can aid in distinguishing syphilis from gonococcemia.


Other conditions to consider in a patient with arthritis and skin lesions include the following:

  • Meningococcemia
  • Hepatitis
  • Bacterial endocarditis
  • Systemic lupus erythematosus (SLE)
  • Tenosynovitis (eg, de Quervain disease, infectious)
  • Other seronegative arthritides - Eg, ankylosing spondylitis, Sweet syndrome, and related dermal vasculitides

Additional considerations

Other conditions to consider in the differential diagnosis of N gonorrhoeae infection include the following:

  • Sexual abuse
  • Enuresis
  • Sexual assault
  • Testicular torsion
  • Trichomoniasis
  • Endometritis
  • Vaginitis
  • Acanthosis nigricans
  • Cutaneous manifestations of hepatitis C
  • Lyme disease
  • Meningococcemia
  • Psoriatic arthritis
  • Syphilis