Gonorrhea differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Gonorrhea must be differentiated from other sexually transmitted pathogens, nongonococcal urethritis, vaginitis, cervicitis, urinary tract infections, prostatitis, and orchitis. Disseminated gonococcal infection must be differentiated from herpes simplex virus (HSV), nongonococcal septic arthritis, syphilis, HIV infection, rheumatic fever, [Reactive arthritis]] , and Lyme disease.

Differentiating gonorrhea from other diseases

Gonorrhea must be differentiated from other sexually transmitted pathogens includ Chlamydia trachomatis, Trichomonas vaginalis, Mycoplasma genitalium, herpes simplex virus (HSV), and syphilis. Conditions that must be considered in the differential diagnosis of gonorrhea:

• In women
  • Nongonorrheal urethritis
  • Vaginitis
  • Cervicitis
  • Urinary tract infections
  • Pregnancy
  • Endometriosis
• In men
  • Nongonorrheal urethritis
  • Prostatitis
  • Orchitis
  • Testicular torsion
  • Urinary tract infections

Disseminated gonococcal infection

Nongonococcal septic arthritis Disseminated gonococcal infection must be differentiated from:

Disease	Findings
Nongonococcal septic arthritis	Presents with an acute onset of joint swelling and pain (usually monoarticular) Culture of joint fluid reveals organisms
Acute rheumatic fever	Presents with polyarthritis and rash (rare presentation) in young adults. Microbiologic or serologic evidence of a recent streptococcal infection confirm the diagnosis. Poststreptococcal arthritis have a rapid response to salicylates or other antiinflammatory drugs.
Syphilis	Presents with acute secondary syphilis usually presents with generalized, pustular lesions at the palms and soles with generalized lymphadenopathy Rapid plasma reagin (RPR), Venereal Disease Research Laboratory (VDRL) and Fluorescent treponemal antibody absorption (FTA-ABS) tests confirm the presence of the causative agent.
Reactive arthritis (Reiter syndrome)	Present with arthritis, tenosynovitis, dactylitis, and low back pain. Extraarticular manifestation include conjunctivitis, urethritis, and genital and oral lesions. There is no definitive diagnostic test. Reactive arthritis is a clinical diagnosis based upon the pattern of findings.
Hepatitis B virus (HBV) infection	Presents with fever, chills, polyarthritis, tenosynovitis, and urticarial rash Synovial fluid analysis usually shows noninflammatory fluid Elevated serum aminotransaminases and evidence of acute HBV infection on serologic testing confirm the presence of the HBV.
Herpes simplex virus (HSV)	Genital and extragenital lesions can mimic the skin lesions that occur in disseminated gonococcal infection Viral culture, polymerase chain reaction (PCR), and direct fluorescence antibody confirm the presence of the causative agent.
HIV infection	Present with generalized rash with mucus membrane involvement, fever, chills, and arthralgia. Joint effusions are uncommon
Gout and other crystal-induced arthritis	Presents with acute monoarthritis with fever and chills Synovial fluid analysis confirm the diagnosis.
Lyme disease	Present with erythema chronicum migrans rash and monoarthritis as a later presentation. Clinical characteristics of the rash and and serologic testing confirm the diagnosis.