Curriculum · Cardiovascular and Hypertension
Peripheral stigmata of infective endocarditis
What it is
The peripheral manifestations of infective endocarditis are its skin, nail and eye findings, and FROM JANE holds them: Fever, Roth spots, Osler nodes, Murmur, Janeway lesions, Anemia, Nail bed hemorrhage, and Emboli. The physical findings for infective endocarditis are petechiae, splinter hemorrhages, Osler's nodes, Janeway lesions and Roth's spots. They are not one group but two, and the split is the one the Duke minor criteria use. 1. Vascular phenomena are embolic: splinter hemorrhages, conjunctival hemorrhages, splenic infarcts, CNS infarcts or ICH, mycotic aneurysms, and Janeway lesions. 2. Immunologic phenomena are the immune ones: Roth's spots, glomerulonephritis, rheumatoid factor, and Osler nodes.
How it presents
Splinter hemorrhages are nonspecific and nonblanching, linear reddish-brown lesions found under the nail bed, and usually do not extend the entire length of the nail. They come from vessel damage by swelling of the blood vessels, that is vasculitis, or from tiny clots that damage the small capillaries, that is microemboli. Osler's nodes are immune and more specific: painful and erythematous nodules, located on the pulp of the fingers and toes, and more common in subacute IE. Janeway lesions are also more specific: erythematous, blanching macules, nonpainful, located on the palms and soles. They are a microabscess of the dermis with marked necrosis and inflammatory infiltrate not involving the epidermis. One page names them in a single line and by the feel of them: the vasculitic lesions of endocarditis are petechiae, splinter hemorrhages, tender fingertip nodules, which are the Osler nodes, and nontender palmar plaques, which are the Janeway lesions. So the word that separates the two in a stem is tender: tender nodules on the pulp of the fingertips are Osler nodes, and nontender plaques on the palm are Janeway lesions. That page puts the vasculitic lesions in 35% of patients, alongside splenomegaly, a new heart murmur and retinal hemorrhages found on physical examination, and it gives fever in 85%, a little below the 90% for fever recorded above, and malaise in 80%, with fever present 98% of the time in IV drug users, so what is held is the range and not one number.