Red spots on soft palate: an atypical peripheral sign of infective endocarditis

A 35-year-old man presented with a five-day history of fever with chills, night sweat, and fatigue. He had a history of congenital ventricular septal defect, which was observed without treatment. He was receiving no medication at the time and had no allergic episode. He was a current smoker had smoked 1-packs-per-day of cigarettes and drank 2 liters of beers each day for 15 years but quit both five days before the presentation. A physical examination revealed multiple dental caries. A cardiovascular examination revealed a harsh, holosystolic murmur which was loudest (intensity grade of 3/6) at the left middle to lower sternum. The rest of the physical examination was unremarkable, and there were no peripheral signs of infective endocarditis, such as Osler's nodes, Janeway's lesions, splinter hemorrhage or petechiae on the mucosal lesions. Laboratory tests revealed elevated C-reactive protein at 11.2 mg/dL (reference range <0.30 mg/dL), an elevated erythrocyte sedimentation rate at 83 mm/hr (reference range <10 mm/hr), and positivity for rheumatoid factor (29 IU/mL; reference range <15 IU/mL). Two sets of blood culture were obtained, and follow-up was scheduled for three days later. Three days after the first visit, the blood cultures grew Aggregatibacter aphrophilus on chocolate agar. A definitive diagnosis of infective endocarditis was made based on the modified Duke criteria. The patient was admitted immediately for treatment. On admission, repeated physical examinations found three, reddish, painless patches on the soft palate (Figure 1, arrows) which were not present at his first visit. No other changes were observed. Treatment with intravenous ceftriaxone was begun, and the palatal spots resolved by the next day. Subsequent transthoracic and transesophageal echocardiography denied vegetation. The red spots never recurred.