One to 4 days of migratory polyarthralgias involving the wrist, knee, ankle, or elbow are common at the outset. Thereafter, two patterns emerge. The first pattern is characterized by tenosynovitis that most often affects the wrists, fingers, ankles, or toes and is seen in 60% of patients. The second pattern is purulent monoarthritis that most frequently involves the knee, wrist, ankle, or elbow and is seen in 40% of patients. Less than half of patients have fever, and less than one-fourth have any genitourinary symptoms. Most patients will have asymptomatic but highly characteristic skin lesions that usually consist of 2 to 10 small necrotic pustules distributed over the extremities, especially the palms and soles.
The peripheral blood leukocyte count averages about 10,000 cells/mcL and is elevated in less than one-third of patients. The synovial fluid white blood cell count usually ranges from 30,000 to 60,000 cells/mcL. The synovial fluid Gram stain is positive in one-fourth of cases and culture in less than half. Positive blood cultures are uncommon. Urethral, throat, cervical, and rectal cultures should be done in all patients, since they are often positive in the absence of local symptoms. Culturing Neisseria gonorrhoeae is facilitated by rapid transport to the microbiology laboratory, inoculation on appropriate media, and incubation in carbon dioxide. Urinary nucleic acid amplification tests have excellent sensitivity and specificity for the detection of Neisseria gonorrhoeae in genitourinary sites.
Radiographs are usually normal or show only soft tissue swelling.