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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 3  |  Issue : 4  |  Page : 106-107

"Janeway Lesions, Osler's Node, and Splinter Hemorrhages in a Case of Acute Infective Endocarditis"


1 Department of Cardiology, Calicut Government Medical College, Calicut, Kerala, India
2 Department of Medicine, Calicut Government Medical College, Calicut, Kerala, India

Date of Web Publication21-Dec-2015

Correspondence Address:
Sandeep Mohanan
Department of Cardiology, Calicut Government Medical College, Calicut, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-449X.168472

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  Abstract 

A 40-year-old female presented with prolonged fever and new-onset seizures. On examination, she was found to have florid peripheral manifestations of infective endocarditis (IE), namely skin petechiae, subconjunctival hemorrhages, Janeway lesions, Osler nodes, and splinter hemorrhages. This helped in early, focused investigation and diagnosis of IE. Peripheral manifestations of subacute IE are rare in the current era of clinical practice owing to early diagnosis and treatment. We present a case where multiple peripheral signs were identified in the same patient.

Keywords: Infective endocarditis, peripheral manifestation, valvular heart disease


How to cite this article:
Mohanan S, Sayed J, Jain R, Jayeshkumar P. "Janeway Lesions, Osler's Node, and Splinter Hemorrhages in a Case of Acute Infective Endocarditis". Heart India 2015;3:106-7

How to cite this URL:
Mohanan S, Sayed J, Jain R, Jayeshkumar P. "Janeway Lesions, Osler's Node, and Splinter Hemorrhages in a Case of Acute Infective Endocarditis". Heart India [serial online] 2015 [cited 2020 Jun 3];3:106-7. Available from: http://www.heartindia.net/text.asp?2015/3/4/106/168472


  Introduction Top


Infective endocarditis (IE) is a life-threatening infection that results from colonization and destruction of endocardial structures, including heart valves, mural endocardium, or implanted prosthetic materials. Despite the decades of experience, reforms in management and early surgical intervention morbidity and mortality rates remain high, varying from 15% to 26%, in various observational studies. [1],[2] However, unlike the past, the index of suspicion has been kept high in the recent times and antibiotics are started early. Unfortunately, many a time, irrational and ineffective antibiotic usage prior to the standard investigations, increase the rates of culture-negative endocarditis, IE relapses, and probably complication rates. [3] In the current clinical practice, the originally described age-old clinical signs of subacute IE are rarely seen. Here, we present a case of subacute IE, who presented with florid peripheral manifestations.


  Case Report Top


A 40-year-old female was presented with generalized tonic-clonic seizures and unconsciousness. She had been having fever for the previous 3 weeks and had no known comorbidities. For the same, she had received short course empirical oral antibiotic therapy on an outpatient basis. On examination in the emergency wing, she was febrile and had neurological findings suggestive of complete left-sided hemiplegia and obtundation. There were erythematous macular lesions on her palms [Figure 1]a, hemorrhagic nodular lesions on the toes [Figure 1]b, splinter hemorrhages on her fingers [Figure 2]a, and subconjunctival hemorrhages [Figure 2]b. The lesions on the palms and toes were identified as Janeway lesions and Osler's nodes, respectively. Cardiovascular examination revealed a loud S1, mid-diastolic murmur, and a short systolic murmur in the mitral area. Blood investigations showed neutrophilic leukocytosis, anemia, and sterile blood cultures. Brain imaging revealed right middle cerebral artery infarct with cerebral edema. Two-dimensional transthoracic echocardiography showed severe mitral stenosis, moderate mitral regurgitation, and a small (8 mm × 3 mm) linear mass on the anterior mitral leaflet prolapsing into the left ventricular outflow tract. A transesophageal study could not be done as she rapidly developed hemodynamic instability. Despite starting broad-spectrum antibiotics and critical care, she succumbed to severe sepsis and cerebral edema.
Figure 1: (a) Janeway lesions are seen as erythematous macular lesions on the palm (b) Osler's node is seen as an hemorrhagic nodule on the big toe. Splinter hemorrhages are also noted on the nail bed of the big toe

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Figure 2: (a) Splinter hemorrhages are seen as linear hemorrhages on the nail bed of the finger (b) subconjunctival hemorrhages are seen on the lower palpebral fissure

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  Discussion Top


Osler's nodes, Janeway lesions, and splinter hemorrhages are rare peripheral manifestations of subacute IE. Osler's nodes (by William Osler) are painful erythematous nodules seen on the pads of fingers or toes. Janeway lesions (by Edward G. Janeway) are painless erythematous macules seen on the palms or soles. Splinter hemorrhages are painless linear hemorrhages found on the nail beds. Though Osler's node is thought to be an immunological phenomenon related to the immune complex deposition and focal vasculitis, all three of them probably have septic microemboli as their pathogenic basis. [4] They are reported to occur at a frequency of 3-5% but are seldom seen in the current clinical practice. [5] In the most recent international collaboration on Endocarditis-Prospective Cohort Study, peripheral signs excluding petechiae were detected overall in less than 10% of patients. [6] This probably reflects the early diagnosis and antibiotic therapy in the current era. The occurrence of all these three findings together in a single patient has only rarely been reported. [7] We present a similar case and emphasize the importance of detailed general examination in any patient presenting with febrile illness.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Netzer RO, Zollinger E, Seiler C, Cerny A. Infective endocarditis: Clinical spectrum, presentation and outcome. An analysis of 212 cases 1980-1995. Heart 2000;84:25-30.  Back to cited text no. 1
    
2.
Mansur AJ, Grinberg M, Cardoso RH, da Luz PL, Bellotti G, Pileggi F. Determinants of prognosis in 300 episodes of infective endocarditis. Thorac Cardiovasc Surg 1996;44:2-10.  Back to cited text no. 2
    
3.
Xiaolu S, Guo-Gan W, Yan-Min Y, Li-Tian Y, Hui-Qiong T, Jun Z, et al. GW25-e5115 Comparison of Characteristics and Outcome From Infective Endocarditis in Blood-culture Negative Endocarditis Versus Blood-culture Positive Endocarditis. J Am Coll Cardiol 2014;64(16_S). doi:10.1016/j.jacc.2014.06.896.  Back to cited text no. 3
    
4.
Alpert JS, Krous HF, Dalen JE, O'Rourke RA, Bloor CM. Pathogenesis of Osler's nodes. Ann Intern Med 1976;85:471-3.  Back to cited text no. 4
    
5.
Divakaramenon SM, Krishnan R, Chandni R. Janeway lesions in infective endocarditis. Heart 2005;91:516.  Back to cited text no. 5
    
6.
Murdoch DR, Corey GR, Hoen B, Miró JM, Fowler VG Jr, Bayer AS, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21 st century: The International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med 2009;169: 463-73.  Back to cited text no. 6
    
7.
Hirai T, Koster M. BMJ Case Rep 2013 Sep 6;2013. doi: 10.1136/bcr-2013-009759.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]



 

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