A 50-year-old man with alcoholic liver disease presented with fever, tenosynovitis, polyarthritis and a vasculitic rash on the hands and feet for 4 days. He had neutrophilia and raised inflammatory markers. He had no history of sore throat, urethral discharge or travel abroad. His initial blood cultures were negative, and he was treated for vasculitis with steroids. The rash and arthritis seemed to improve initially, but he had another episode of fever. Repeat blood cultures grew Neisseria gonorrhoeae,and he received intravenous ceftriaxone followed by oral ciprofloxacin. He had marked improvement in rash, tenosynovitis and arthritis, and the fever dropped. He also had chlamydial urethritis and received azithromycin. The presentation of disseminated gonococcal infection after a presumptive episode of asymptomatic urethral gonorrhoea is highlighted.A 50-year-old car mechanic was admitted with a 4-day history of fever (39.4˚C) with chills and swollen, tender, stiff hands and feet. He also had red spots on the hands and feet. There was no history of sore throat, urethral discharge, red eye or tick bite. He had alcoholic liver disease but continued to drink .60 units of alcohol weekly. He had had attacks of gout in the first metatarsophalangeal joints and osteoarthritis of the right knee in the past.On examination, he had asymmetrical arthritis involving the wrists, ankles, and metacarpophalangeal, proximal interphalangeal and metatarsophalangeal joints. There was tenosynovitis on the dorsal aspect of the wrists and ankles. There was an erythematous maculopapular non-pruritic vasculitic rash on the upper and lower extremities.Laboratory findings showed a slightly raised white blood cell count of 11.3, with a C reactive protein (CRP) level of 139 mg/l. Tests for rheumatoid factor, antinuclear antibody and antineutrophil cytoplasmic antibody were negative. Immunoglobulins were normal, C3 was normal but C4 was slightly low. Cryoglobulin was not detected. Hepatitis screen was negative. The initial two sets of blood cultures showed no growth. He was treated for cutaneous vasculitis with intravenous methylprednisolone followed by oral prednisolone. He was afebrile, the rash resolved, and the arthritis and tenosynovitis showed improvement in the first week.In the second week, he was unwell with fever (39˚C), tenosynovitis, arthritis and rash (fig 1A-D). Investigations showed white cell count 37.4610 9 , neutrophils 94%, and CRP 42. Repeat blood cultures grew Neisseria gonorrhoeae. He was treated with intravenous ceftriaxone 2 g daily for 5 days followed by oral ciprofloxacin 500 mg twice daily for a week. He became afebrile with complete resolution of the rash and marked improvement in the arthritis and tenosynovitis 3 days after starting ceftriaxone treatment. CRP dropped to 12 mg/L. On inquiry, he admitted having had a casual sexual contact 6 weeks preceding the illness. Further screening for sexually transmitted diseases confirmed infection with Chlamydia trachomatis, for which he was given 1 g of azithromycin. His regu...