VA Report: Peripheral Stigmata of Infective Endocarditis

A morning of endocarditis at the VA and Moffitt!  Today we discussed the peripheral lesions classically associated with the disease.

Peripheral Stigmata of Infective Endocarditis
 Pearls:

  • The characteristic peripheral stigmata of infective endocarditis are seen in approximately 25% of patients with IE.
  • Petechiae are the most common skin manifestation of IE.
  • The most common causes of splinter hemorrhages are trauma and psoriasis.
  • Splinter hemorrhages due to systemic disease are often seen in the proximal nail, whereas those due to trauma are often distal.

Janeway lesions are described as painless erythematous macules on the palms and soles felt to be the result of septic emboli in infective endocarditis.

Osler’s nodes, on the other hand, are described as painful erythematous nodules on the fingers, toes, or feet that result from immune-complex deposition. Osler’s nodes are thought to be seen more commonly in subacute endocarditis.

However, it seems that – in actuality – Janeway lesions and Osler’s nodes are not as clinically distinct as we may think.  LT referenced a classic paper by Farrior & Silverman published in CHEST in 1976 that looks at the two notorious phenomena. The paper concluded that the only essential diagnostic difference between the two is that Osler’s nodes are tender and Janeway lesions are not (see the paper below)!

Roth spots have classically been described as an embolic phenomenon and pathognomonic for subacute bacterial endocarditis. However, it seems the underlying pathogenesis is actually retinal capillary rupture rather than septic emboli.

Splinter hemorrhages are the least specific of the classically described peripheral stigmata of endocarditis. They generally appear as red/black small thin longitudinal lines under the nail plate. The most common causes of splinter hemorrhages are trauma and nail psoriasis. They can also result from systemic diseases, including connective tissue diseases, antiphospholipid syndrome, chronic renal failure, trichenellosis, in addition to endocarditis. Splinter hemorrhages associated with systemic diseases are often proximal in the nail, whereas those due to trauma are usually distal. However, all splinter hemorrhages grow out distally.

Petechiae are non-specific, but the most common skin manifestation of infective endocarditis.

Farrior JB, Silverman ME. A consideration of the differences between a Janeway’s lesion and an Osler’s node in infectious endocarditis. CHEST. 1976 Aug;70(2):239-243. Farrior and Silverman. CHEST 1976.

Schwartz BS. “Bacterial & Chlamydial Infections.” Current Medical Diagnosis and Treatment. McGraw Hill Medical; 2013: 1435-37.

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