A previously healthy 15-year-old girl presents to the emergency department with pain, swelling, redness, and decreased movement of the left fourth and fifth digits. Twelve days before her presentation, she developed left hand pain and swelling. She was taking acetaminophen for pain with minimal relief. Four days before presentation she was seen by her primary care physician, where she was prescribed a 5-day course of oral corticosteroids for unclear reasons. She noted improvement the following day, but 2 days before her presentation she developed worsening left hand pain, swelling, and overlying redness. On the day of presentation, she developed decreased movement in the fourth and fifth digits of her left hand, which prompts her presentation to the emergency department. She denies fevers, chills, night sweats, appetite changes, nausea, vomiting, diarrhea, rash, or any other joint pain. She denies any preceding trauma or known breaks in the skin of her left hand. She does not have a history of serious bacterial infections. She has not experienced joint pain or swelling in the past. She lives in a camper in rural Arkansas. She has a dog, pigs, and chickens. She reports 1 sexual encounter with a male partner a year earlier and states that her partner used a condom. She denies alcohol, tobacco, and intravenous or other drug use. She reports regular menstrual cycles and denies intermenstrual spotting, pelvic pain, or vaginal discharge either before or after her sexual encounter. The onset of her last menstrual period was 2 to 3 days before the onset of symptoms and was on time and regular.On presentation she is a well-appearing and nontoxic teenager. She is afebrile, with a heart rate of 88 beats/min, respiratory rate of 18 breaths/min, and blood pressure of 115/72 mm Hg. On physical examination her oropharynx is normal, without pharyngitis or enanthem. Auscultation reveals normal S1 and S2 heart sounds without a murmur, and lung fields are clear. No exanthem or skin lesions are present. Her abdomen is soft, without hepatosplenomegaly or abdominal or pelvic tenderness to palpation. She has swelling of the lateral portion of the left hand with overlying erythema, warmth, and tenderness. Her fourth and fifth digits remain in the flexed position. She refuses to actively move these fingers at the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal joints due to pain. She has pain with passive movement of the fifth digit with difficulty determining exact location of pain. She has tenderness to palpation of the dorsum of her hand, in the region of her fifth MCP joint. There is no break in her skin or drainage. The remainder of her joints are unaffected, with full range of motion. Initial laboratory studies obtained in the emergency department reveal a white blood cell count of 11,400/μL (11.40 × 109/L) (reference range, 4,500–13,500/μL [4.50–13.50 × 109/L]), with 62.8% neutrophils, 26.8% lymphocytes, and 8.2% monocytes. Her platelet count is 353 × 103/µL (353 × 109/L) (reference range, 150–400 × 103/μL [150–400 × 109/L]). Her C-reactive protein level is 2.8 mg/dL (28 mg/L) (reference range, 0.0–0.939 mg/dL [0.0–9.39 mg/L]) and erythrocyte sedimentation rate is 27.0 mm/hr (reference range, 0–20 mm/hr). A single blood culture is obtained. A radiograph of the left hand shows osseous destruction of the fifth metacarpal head. Contrast magnetic resonance imaging reveals 1) extensive edema and enhancement throughout the entire fifth metacarpal (Fig) and near entirety of the fifth proximal phalanx consistent with osteomyelitis; 2) subtle osseous irregularity/destruction of the fifth metacarpal head; 3) bulky synovial thickening and enhancement of the fifth MCP joint; 4) mild reactive synovitis of the fifth PIP joint; 5) extensive soft tissue edema and enhancement compatible with cellulitis overlying the dorsum and volar-lateral portions of the hand, and 6) myositis surrounding the fifth metacarpal and fifth digit.The patient was hospitalized and underwent irrigation and debridement of the left fifth MCP joint, fifth metacarpal, and proximal phalangeal bones with placement of a Penrose drain. Intraoperative findings were significant for septic arthritis of the fifth finger MCP joint with extensive purulence around the fifth metacarpal extending from the fifth MCP joint into the web space between the fourth and fifth metacarpals. Erosion of the fifth metacarpal head was also noted. Intraoperative aerobic and anaerobic cultures were sent. After surgery, she was started on empirical antimicrobial treatment with cefazolin. Clindamycin was added on the advice of infectious diseases due to local community prevalence of methicillin-resistant Staphylococcus aureus. On the third day of admission, intraoperative aerobic wound cultures revealed growth of a gram-negative diplococci, which was confirmed to be Neisseria gonorrhoeae. Her blood culture remained negative.Osteomyelitis is relatively common in pediatrics, with an overall incidence of 8 to 10 cases per 100,000 person-years. (1) Neisseria gonorrhoeae is a rare cause of osteomyelitis, with only 3 previously reported pediatric cases in the literature. (2)(3)(4)Disseminated gonococcal infection (DGI) is a consequence of invasion of the bloodstream from localized infection of the mucous membrane of the genital tract, rectum, pharynx, or conjunctiva. (5) This hematogenous dissemination, which may occur in 1% to 3% of all gonococcal infections, (6) can subsequently seed other sites. Dissemination is more common with asymptomatic mucosal infections, (5) likely due to a delay in diagnosis and appropriate treatment.DGI most commonly falls into 2 clinical syndromes: the first and most common is arthritis-dermatitis syndrome (also referred to as tenosynovitis-dermatitis syndrome) and the second is suppurative arthritis syndrome. (6) Rarely, manifestations of DGI include endocarditis and meningitis; osteomyelitis is also a rare form of DGI. The mechanism of gonococcal osteomyelitis may be by hematogenous spread or by contiguous spread from an adjacent infected joint; the latter mechanism of infection is favored by the fact that a delay between presentation and initiation of treatment is a common risk factor for those with gonococcal osteomyelitis. (7)The patient’s initial onset of pain may have been due to septic arthritis of the MCP joint, with or without contiguous osteomyelitis at the time. The most common cause of joint disease in hospitalized children is septic arthritis. (8) The differential diagnosis of septic arthritis in the pediatric population includes transient synovitis, juvenile idiopathic arthritis (JIA), reactive arthritis, or other inflammatory diseases. During the first weeks of disease, differentiating between septic arthritis and JIA may be challenging. JIA corresponds to an arthritis of unknown etiology that continues for a minimum of 6 weeks. (9) As such, infection should be ruled out via joint aspiration and microbiological studies before considering treatment with corticosteroids for inflammatory causes. (10)Management of DGI includes ceftriaxone until susceptibilities are available, with consideration to switch adolescent patients to a susceptible oral antibiotic 24 to 48 hours after substantial clinical improvement is noted, for a minimum of 7 days of total therapy. A single dose of oral azithromycin should also be prescribed due to the possibility of concomitant Chlamydia trachomatis infection. (11) Gonococcal osteomyelitis is an uncommon occurrence in DGI; as a result, the standard duration of therapy is not well-defined. In the 3 previously published pediatric cases, antibiotic regimens included a combination of parenteral and enteral therapy: intravenous (IV) penicillin for an unknown duration for PIP infection, (2) 3 weeks of IV penicillin followed by 3 weeks of oral penicillin for MCP joint infection, (3) and ceftriaxone for 9 days followed by 35 days of oral cefixime for right humeral head infection. (4) The 2 patients treated with penicillin were reported in the 1970s, before the recognition of increasing rates of antibiotic resistance. (12)(13) In adult patients, variable durations of treatment have been used: smaller bone infections have been successfully treated with 1 week of antibiotic therapy, (14) and cases involving long bones have been treated with a combination of parenteral and enteral antimicrobials for a total of up to 8 weeks. (15)When N gonorrhoeae was identified as the etiology, antibiotic therapy was changed to IV ceftriaxone, 1 g once daily. She also received a single dose of azithromycin, 1 g orally. A urine sample detected N gonorrhoeae by nucleic acid amplification test, whereas Chlamydia trachomatis by nucleic acid amplification test was not detected. Human immunodeficiency virus and syphilis screening were negative. IV ceftriaxone was continued for a total of 14 days. Her inflammatory markers (C-reactive protein and erythrocyte sedimentation rate) had normalized; however, functional recovery of the joint was incomplete, with inability to actively move the fifth digit at the MCP joint at the time of discharge.The patient’s mother was aware of her sexual history, and her diagnosis was disclosed to the mother with the patient’s permission. The patient’s sexual partner was advised to be evaluated and treated. The patient was counseled on safe sex practices, namely, the use of barrier protection methods to help prevent sexually transmitted infections.Gonococcal osteomyelitis is a rare form of disseminated gonococcal infection and may be associated with a contiguous arthritis.Neisseria gonorrhoeae should be considered as an etiology in osteomyelitis with contiguous joint infections in sexually active children.Antibiotic therapy should be guided by antimicrobial susceptibilities; the overall duration of therapy is variable, with case reports noting shorter courses for small bones and longer durations for long bones.Cautious use of corticosteroids for arthritis in children should be practiced until infection is ruled out.