CLINICAL IMAGE TEXT DESCRIPTION
A 74-year-old woman presented with fatigue and worsening dyspnea. On examination, she was febrile, tachycardic, and tachypneic, with a pansystolic murmur. A painless erythematous nodule was noted on her right hypothenar eminence (Fig. 1). Chest x-ray showed bilateral ill-defined airspace opacities. Blood culture grew methicillin-sensitive Staphylococcus aureus. Transesophageal echocardiography revealed an abscess on the posterior mitral leaflet (Fig. 2), confirming the diagnosis of infective endocarditis.
Figure 1.
Photograph showing a Janeway lesion on right hypothenar eminence.
Figure 2.
Transesophageal echocardiogram showing a cystic structure on the posterior mitral leaflet, suggestive of an abscess.
Janeway lesions and Osler’s nodes are both classic stigmata of endocarditis, but distinguishing the two can be difficult. Janeway lesions are nontender hemorrhagic macules or papules located on palms, soles, and thenar and hypothenar eminences. Osler’s nodes are painful violaceous nodes typically found on fingers and toes. Traditionally, Janeway lesions have been attributed to septic emboli and Osler’s nodes described as an immunologic phenomenon. However, histologic evaluation of the two shows significant overlap. Both have been associated with neutrophilic vasculitis, microabscesses, and pathologic organism on culture.1–3 The most widely agreed upon difference between Janeway lesions and Osler’s nodes is that the former is painless, whereas the latter is painful.2 Classic skin manifestations of infective endocarditis are associated with a higher risk of complications and remain an important clinical finding.3
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References
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