Sure Signs
Article Outline
Presentation
A 33-year-old Caucasian man presented to the emergency department after the sudden onset of severe pain and discoloration in his fingers and toes. He denied any significant past medical history. His symptoms included a temperature of 100.4° F (38.0° C), erythematous and blue-black macules on the palmar surface of the right hand and sole of his feet, and a tender, palpable, lesion on the radial aspect of the right index finger (Figure 1, Figure 2).
Figure 1.
Janeway lesions appeared on the sole of this patient’s foot.
Figure 2.
An Osler’s node developed on the radial aspect of the index finger.
Assessment
The patient’s clinical cardiac examination was normal, and he had good peripheral pulses. On detailed questioning, he admitted that he was an active intravenous drug user. Blood cultures grew Staphylococcus aureus that was sensitive to penicillin. A transesophageal echocardiogram showed vegetations on the mitral valve.
Diagnosis
The erythematous macules seen in this patient were classic Janeway lesions, originally described by Edward Janeway as a means of differentiating bacterial endocarditis from other infectious disorders.1 These painless, pink, irregular macules mainly appear on the thenar and hypothenar eminences of the hands and feet.2 The tender, palpable, lesion on the radial aspect of the patient’s right index finger was an Osler’s node, a painful, nodular lesion that primarily forms on the terminal phalanges of the fingers or toes.3 Like Janeway lesions, Osler’s nodes are a pathognomonic—if rarely manifested—sign of bacterial endocarditis. A histological examination of Janeway lesions typically reveals neutrophilic infiltration, necrosis, and subcutaneous hemorrhage, while Osler’s nodes are marked by necrotizing vasculitis of the glomus body and inflammatory infiltration.
Most patients with endocarditis have an identifiable risk factor, so a detailed history is helpful in reaching a diagnosis. Congenital or degenerative heart disease, recent placement of an indwelling intravascular catheter, prosthetic heart valves, and intravenous drug abuse are all predisposing elements. Careful auscultation of the heart might reveal a new murmur, a change in an existing heart murmur, or even signs of congestive heart failure. Other clinical signs can include evidence of emboli to the fundi of the eyes, the conjunctivae, or the skin. Although any bacteria can cause endocarditis, Staphylococcus aureus, Streptococcus viridans, and enterococcus species account for the majority of cases.
Management
Combination therapy with a beta lactam agent and an aminoglycoside is effective in treating streptococcal or enterococcal endocarditis. Semisynthetic penicillins, such as nafcillin or oxacillin, are preferred for treating staphylococcal endocarditis of a native valve.4 Cefazolin or ceftriaxone can be used in patients with penicillin allergy, as long as no prior history of Type 1 (immediate) hypersensitivity reaction to penicillin exists. For patients who have experienced an immediate hypersensitivity reaction to penicillin, vancomycin can be used, despite its poorer penetration into vegetations and slower bactericidal activity.5 Note that this is the only situation in which vancomycin should be used to treat bacterial endocarditis. Our patient received intravenous nafcillin and gentamicin.
Even though the cutaneous manifestations of endocarditis are well-described in textbooks, they are seldom seen in clinical practice, and as a result, physicians could have difficulty identifying them. In addition, these skin lesions can have overlapping features, and differentiating one from the other does not necessarily provide clinically significant information. However, in this era of high-tech medicine, a clinical scenario like this one stresses the enduring importance of a good history and physical examination in the diagnosis of a life-threatening condition.
References
- . A consideration of the differences between a Janeway’s lesion and an Osler’s node in infectious endocarditis. Chest. 1976;70:239–243
- . Janeway lesions: differential diagnosis with Osler’s nodes. Int J Dermatol. 1993;32:673–674
- . Janeway lesions and Osler’s nodes: A review of histopathologic findings. J Am Acad Dermatol. 1990;22(6 Pt 1):1088–1090
- Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America. Circulation. 2005;111:e394–e434
- . Guidelines for the antibiotic treatment of endocarditis in adults: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother. 2004;54:971–981
Parwathi “Uma” Paniker, MD, Section Editor
PII: S0002-9343(06)01257-5
doi:10.1016/j.amjmed.2006.10.011
© 2007 Elsevier Inc. All rights reserved.
