Clinical picture

It’s all in the hands: peripheral stigmata of infective endocarditis A 35-year-old female with a background of intraven-ous drug use, infective endocarditis, Hepatitis C and alcohol abuse presented with generalized weakness and malaise. She had previously been admitted for infective endocarditis but was discharged against medical advice. During this current admission, three sets of blood cultures were taken over a 24-h period and all three sets grew methicillin-resistant Staphylococcus aureus (MRSA). Transthoracic echocardiogram that was performed demonstrated vegetations on the mitral and tricuspid valves. Patient was started on intravenous vancomycin and advised strongly to complete 6 weeks of antibiotics therapy. With the early recognition of infective endocardi-tis and effective treatment with antibiotics, periph-eral stigmata of infective endocarditis such as Janeway’s lesion, Osler’s node and splinter haemor-rhage have become increasingly rare in the de-veloped world. In this patient, her refusal for treatment had resulted in her developing these vas-cular complications such as Janeway lesion (non-tender, erythematous macules) (Figure 1A) and sphinter haemorrhage (Figure 1B). Janeway lesions have been classically described as small hemor-rhages with slight nodular character in the palms of the hand and soles of the feet while Osler nodes were described as ephemeral spots of a painful nodular erythema chiefly in the skin of the hands and feet.1,2 It is, therefore, important for phys-icians to recognize these signs and have a high index of suspicion for infective endocarditis when patients present with them