A 32-year-old man is brought to the emergency department with a several-day history of high-grade fever, dyspnea, and fatigue. The patient's temperature is 39.4 C (102.9 F), blood pressure is 122/70 mm Hg, and pulse is 102/min and regular. Physical examination reveals a new holosystolic murmur with a blowing quality that is best heard over the cardiac apex. Skin examination shows nontender lesions on the sole of the feet, as shown in the image below. Which of the following do these lesions most likely represent?

Question

A 32-year-old man is brought to the emergency department with a several-day history of high-grade fever, dyspnea, and fatigue.  The patient's temperature is 39.4 C (102.9 F), blood pressure is 122/70 mm Hg, and pulse is 102/min and regular.  Physical examination reveals a new holosystolic murmur with a blowing quality that is best heard over the cardiac apex.  Skin examination shows nontender lesions on the sole of the feet, as shown in the image below.  Which of the following do these lesions most likely represent?

Quizplus · Accepted Answer

11ec160b_38cc_7f03_9249_efba931f9cd0_MD0001_00 This patient's presentation (fever, dyspnea, and a new blowing holosystolic murmur best heard at the cardiac apex) is suggestive of mitral regurgitation likely due to infective endocarditis (IE). Patients with IE can develop several peripheral cutaneous or mucocutaneous stigmata of endocarditis including petechiae, splinter hemorrhages, Roth spots, Janeway lesions (see above Image), and Osler nodes. Janeway lesions are nontender, macular, and erythematous lesions typically located on the palms and soles. They are the result of septic embolization from valvular vegetations and are composed of bacteria, neutrophils (microabscesses), necrotic material, and subcutaneous hemorrhage. (Choice A) A neoplastic proliferation of cells of vascular origin (eg, Kaposi sarcoma) cannot be ruled out based on the appearance of this patient's skin lesions alone. However, the overall clinical presentation is highly suggestive of bacterial endocarditis as the unifying diagnosis. (Choice B) Granulomatous inflammation can produce cutaneous lesions in miliary tuberculosis, sarcoidosis, and leprosy. However, the lesions do not localize preferentially to the soles of the feet. (Choice C) Osler nodes are tender, violaceous nodules typically located in the pulp of fingers and toes. The pathogenesis of Osler nodes is immune-complex deposition in the skin. (Choice E) The lesions on the sole of the foot could represent primary foci of infection as might occur following focal skin abrasions/puncture or from sporotrichosis after walking barefoot. However, this patient's symptoms are most suggestive of mitral valve IE. Educational objective: Janeway lesions are nontender, macular, and erythematous lesions typically located on the palms and soles of patients with acute infective endocarditis and are the result of septic embolization from valvular vegetations.

A 32-Year-Old Man Is Brought to the Emergency Department with a Several-Day