‘Diagnostic hands’: Janeway lesions—a forgotten entity

A 76-year-old woman presented in cardiology clinic with New York Heart Association class II dyspnoea for the last 4 months. She had a history of severe mitral and moderate aortic stenosis that required double mechanical valve replacement 15 years ago. B-type natriuretic peptide was normal, and transthoracic echocardiogram showed that both prostheses had similar gradients to the last ones measured. Pulmonary function tests were normal. The patient kept referring persistent dyspnoea and other non-specific symptoms. Physical examination revealed significant aortic and mitral systolic murmurs. Erythematous painless macules on the palms and dark red subungual lesions in the nail beds of the fourth finger were found on both hands (Figure 1). Routine blood cultures detected growth of Streptococcus gordonii. Although initial transthoracic echocardiogram could not detect any vegetation, a transoesophageal echocardiogram was performed and showed two mobile images in the atrial side of the mitral ring of 7 mm in length, suggesting vegetation, causing a mild periprosthetic leak in the mitral–aortic junction. F-fluorodeoxyglucose (F-FDG) positron emission tomography (PET)/computed tomography (CT) was performed due to the limitation of echocardiogram, and revealed two foci of hypermetabolism, in the aortic and predominantly the mitral valve (Figure 2). According to modified Duke Criteria, patient was diagnosed of definite infective endocarditis fulfilling two major (positive echocardiography, abnormal activity around the site of prosthetic valve implantation by ¹⁸F-FDG PET/CT) and three minor criteria (predisposing heart condition, vascular phenomena—Janeway lesions—and positive blood culture). The case was discussed in a multidisciplinary heart team and a conservative medical approach based on ceftriaxone was decided. Janeway lesions are irregular, painless, erythematous or haemorrhagic macules, or papules commonly found on the palms and soles. The pathogenesis of Janeway lesions is still a controversial topic in the literature, but the main hypothesis is based on septic embolic events. Although current diagnosis of endocarditis is unlikely to be made only on the basis of Janeway lesions, the use of classic cutaneous signs of this entity could not be forgotten by clinicians, even in the post-antibiotic era of the developed world, to achieve the correct diagnosis.

Figure 1.

Janeway lesions: irregular, painless, erythematous, or haemorrhagic macules or papules on the palms.

Figure 2.

(A) Transoesophageal echocardiogram showed two mobile images in the atrial side of the mitral ring of 7 mm in length. (B) F-fluorodeoxyglucose positron emission tomography/computed tomography revealed foci of hypermetabolism in the aortic and predominantly the mitral valve.

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Conflict of interest: none declared.

Funding: none declared.