Clinical features of infective endocarditis

Q: A 52-year-old male with a history of End Stage Renal Disease (ESRD) is admitted to the ICU with suspected infective endocarditis (IE). On clinical exam found to have Janeway lesions. Janeway lesions are more common in? - select one

A) acute IE

B) subacute IE

Answer: A

Clinical exam in IE plays an important role. Three hallmark characteristic findings, though relatively uncommon, are highly suggestive of IE:

• Janeway lesions
• Osler nodes 
• Roth spots 

Janeway lesions are nontender erythematous macules on the palms and soles. Histologically, they are microabscesses with neutrophil infiltration of capillaries. Janeway lesions are more common in acute than subacute IE. 

In contrast, Osler nodes and Roth spots occur over a protracted time course of endocarditis. These two entities are sequelae of microthromboembolic occlusion, leading to localized immune-mediated vasculitis. Osler nodes, in contrast to Janeway lesions, are tender and subcutaneous (SQ) violaceous nodules mostly on the pads of the fingers and toes, and may also occur on the thenar and hypothenar eminences. Interestingly, tenderness begins a few days before the nodule appears. Roth spots are exudative, edematous, hemorrhagic lesions of the retina with pale centers.

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References:

1. Saccente M, Cobbs CG. Clinical approach to infective endocarditis. Cardiol Clin. 1996 Aug;14(3):351-62. doi: 10.1016/s0733-8651(05)70289-7. PMID: 8853130.

2. Loughrey PB, Armstrong D, Lockhart CJ. Classical eye signs in bacterial endocarditis. QJM 2015; 108:909.

3. Abdelgawad H, Azab S, Abdel-Hay MA, Almaghraby A. Clinical features and outcomes of infective endocarditis: a single-centre experience. Cardiovasc J Afr. 2023 May-Jun 23;34(2):82-88. doi: 10.5830/CVJA-2022-027. Epub 2022 Aug 3. PMID: 35924572; PMCID: PMC10512034.