Splinter Hemorrhage

Case Report

A 56-year-old man with a history of bioprosthetic aortic valve replacement presented to the emergency department from the cardiology clinic with concern for COVID-19. He was febrile to 39.0°C but was otherwise asymptomatic. On physical examination, he exhibited a loud systolic murmur with vertical, nonblanching, reddish-brown lines underneath the nail plates to the left hand, consistent with splinter hemorrhages (Figure 1 ). No other signs of septic emboli were identified on physical examination. During his admission, blood cultures returned positive for haemophilus parainfluenzae and his clinical course was complicated by left occipital lobe infarction with consequent visual loss to the left eye. A 6-week antimicrobial course was initiated for bacteremia resolution and he was followed closely by cardiothoracic surgery for prosthetic valve endocarditis.

Figure 1.

Vertical, nonblanching, reddish-brown lines underneath the nail plates to the left hand consistent with splinter hemorrhages.

Discussion

Splinter hemorrhages in endocarditis develop as a consequence of septic embolization from an original source of infection, for example, valvular or pacemaker vegetation, or infected thrombus on indwelling vascular catheter or graft (1). Smaller particles of the source infection subsequently dislodge and travel via the bloodstream to distant blood vessels, resulting in microvascular occlusion.

Splinter hemorrhages represent rupture of longitudinally oriented nail plate capillaries leading to extravasation and the historical hallmark of linear discoloration. They were first described in 1923 by George Blumer, who described them as “splinters under the nail” in patients with subacute bacterial endocarditis, leading to their commonly taught association in medical and residency education (2). Most often, however, they are due to trauma, for example, nail biting or using a cane, and manifest distally to the nail (2). Comparatively in systemic diseases, for example, bacterial endocarditis, the splinter hemorrhages develop proximally and occur in multiple nails (1).

When encountering splinter hemorrhages, the emergency clinician should consider the possible sources for septic embolization, such as septic thrombophlebitis, central venous catheter infections, Foley catheter infections, and graft infections or graft failures (3). In addition, bacterial sepsis, for example, meningococcemia, can cause splinter hemorrhages due to capillary fragility, autoimmune conditions, for example, systemic lupus erythematosus via immune-mediated vasculitis, and underlying malignancy from heightened cellular turnover (3). Identification of splinter hemorrhages should always raise concern for critical illness and further reinforces the importance of meticulous and detailed physical examination in the care of our patients.