Description
A 35-year-old woman presented with breathlessness and palpitations for 1 year. She had an irregular pulse and a mid-diastolic rumbling murmur on auscultation. There were non-tender, small (2–4 mm in diameter) haemorrhagic macular lesions on her both soles (figure 1). A transthoracic echocardiography showed severe mitral stenosis and mitral regurgitation suggestive of rheumatic heart disease. There was a large clot in the left atrium but no vegetations suggestive of infective endocarditis (IE). Serial blood cultures were sterile. Her coagulation screen was normal. Skin biopsy was done which showed evidence of dermal infiltrate of lymphocytes and histiocytes along with vascular thrombosis—suggestive of cutaneous microembolism, likely from the intracardiac thrombus.
Figure 1.
Patient of rheumatic heart disease with intracardiac thrombus showing small haemorrhagic macular lesions on both soles looking like Janeway’s lesions
Janeway’s lesions are painless, macular, haemorrhagic lesions occurring most commonly on the palmar surface of the hands and feet. Histopathological examination usually reveals perivascular infiltrate of neutrophils and endothelial swelling1 and dermal microabscesses without evidence of vasculitis and thrombosis of the small vessels.2 Similar to Janeway’s lesion, cutaneous microembolism may present with non-tender erythematous lesions over fingers and toes in patients with rheumatic heart disease. Besides intracardiac thrombus, cutaneous microembolism may be found in systemic lupus erythematosus, leucocytoclastic vasculitis, haemolytic anaemia and gonococcemia.3 Absence of other features of IE, evidence of a source of emboli and finally a skin biopsy may help in differentiating these two entities. Cutaneous microembolism should be considered as a close differential diagnosis of Janeway’s lesion.
Patient’s perspective.
When I had fever and spots on the skin, my doctor said that I was probably having infection of the heart valves, which might require long-term IV drugs and even surgery. However after proper evaluation it was proved to be due to showering of clots from my heart. These spots decreased after blood thinning agents. It was such a relief to me that it was not as serious as I feared initially.
Learning points.
Cutaneous microembolism may be a close mimic of Janeway’s lesion.
Besides intracardiac thrombus, cutaneous microembolism may be found in other diseases like systemic lupus erythematosus, leucocytoclastic vasculitis, haemolytic anaemia and gonococcemia.2
Footnotes
Contributors: SJDBK wrote the manuscript. AR, NB and NKV edited the manuscript.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Obtained.
References
- 1. Lian C, Nicolau S, Poincloux P. Histopathologie de nodule d Osler: e tude sur l' endotheliiite de l' endocardite maligne a evolution lente. Press Med 1929;37:497–9. [Google Scholar]
- 2. Sethi K, Buckley J, de Wolff J. Splinter haemorrhages, Osler’s nodes, Janeway lesions and Roth spots: the peripheral stigmata of endocarditis. Br J Hosp Med 2013;Sep 1;74(Sup9:C139–42. [PubMed] [Google Scholar]
- 3. Johnston GA, Graham-Brown RA. et al. Skin manifestations of internal organ disorders : Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller SA, Leffell D,. Fitzpatrick’s Dermatology in general medicine. 2 7th ed New York: McGraw Hill, 2008:1445–60. [Google Scholar]