A 53-year-old man with history of HIV presented with one day of left wrist and hand pain, swelling, and associated painful movement and tenderness to palpation. This progressed over several hours to include bilateral shoulder pain and right ankle pain that came in waves. Laboratory studies revealed white blood cell count of 22 × 10³/µL, CK of 2,585 U/L and CRP of 158 mg/L. He denied dysuria, but endorsed subjective fever. He also reported unprotected receptive intercourse with an anonymous contact 1 week prior. MRI of the left wrist demonstrated effusion within the radiocarpal, distal radioulnar and intercarpal joints (image A), as well as tenosynovial effusion suggestive of tenosynovitis of the extensor tendons (image B). Chlamydia trachomatis and Neisseria gonorrhoeae urinary testing were negative, but blood cultures grew Neisseria gonorrhoeae. A peripherally inserted central catheter line was placed and the patient was discharged to complete 4 weeks of ceftriaxone.