A case series of skin manifestations of infective endocarditis in contemporary era: just another book finding or a useful clinical sign?

Abstract

Background: Infective endocarditis (IE) is a disease of high morbidity and mortality. Infective endocarditis rarely involves skin manifestations in the contemporary era. The identification of typical skin lesions could be helpful in establishing early diagnosis of IE.

Case summary: We present four cases of IE hospitalized in our institution within a 12-month period. All patients were young and had skin manifestations on initial presentation (petechiae, splinter haemorrhages, Janeway lesions, and Osler's nodes), which led to a high clinical suspicion of IE confirmed by echocardiography and positive blood cultures. All cases had a complicated course. One patient died and the other three had prolonged hospital stay due to variable complications.

Discussion: Clinicians should always assess for skin manifestations in patients with fever especially when suspicion of IE is high. Occurrence of skin lesions in the course of IE may be associated with higher rate of complications and worse prognosis.

Keywords: Case series; Infective endocarditis; Janeway lesions; Osler’s nodes; Skin; Splinter haemorrhages.

Figure 1

(A) Janeway lesion (white arrows) and (B) splinter haemorrhages (white arrows).

Figure 2

(A) Long-axis midoesophageal transoesophageal echocardiography view demonstrating large vegetations (maximum diameter of ∼2.4 cm) on the mitral valve and (B) four-chamber midoesophageal transoesophageal echocardiography view zoomed in the mitral valve with colour showing two large mitral regurgitation jets (vena contracta of 6 and 4 mm) due to deformation of the valve from infective endocarditis.

Figure 3

(A) Multiple Janeway lesions (white arrows) and (B) Osler’s nodes (white arrows).

Figure 4

(A) Long-axis midoesophageal transoesophageal echocardiography view demonstrating large vegetations (white arrows) on the mitral valve; (B) mycotic aneurysm of the superior mesenteric artery on axial computed tomography images of the abdomen (white arrows); (C) reconstructed 3D image showing the mycotic aneurysm (white arrows); and (D) no signs of active inflammation of the aneurysm were seen on PET scan imaging.

Figure 5

(A) Multiple Janeway lesions (white arrows) and Osler’s nodes (white arrowheads); (B) splinter haemorrhages (white arrows); (C) conjunctival haemorrhage; and (D) gangrene of the right foot.

Figure 6

(A) Long-axis midoesophageal transoesophageal echocardiography view zoomed in the aortic valve showing vegetations (white arrowheads) on the aortic valve and (B) resultant severe aortic regurgitation (vena contracta ∼5 mm).

Figure 7

(A) Multiple petechiae (white arrows showing most representative ones) and (B) splinter haemorrhage (white arrow).

Figure 8

(A) Long-axis midoesophageal transoesophageal echocardiography view demonstrating vegetations on the aortic valve; (B) holodiastolic flow reversal in the abdominal aorta (white arrows) indicating severe aortic regurgitation; (C) left kidney infarct on abdominal computed tomography (white arrowheads); and (D) intracerebral haemorrhage on head computed tomography (white arrows).