Core Dermatology Diagnoses / CategoriesInfectious

Cutaneous Signs of Endocarditis

Author: Deputy Editor: Faculty Reviewer:

Publish date: Posted on
Last updated: February 17, 2024

Keywords #

infective endocarditis
endocarditis
left-sided endocarditis
IE
Janeway lesions
Osler nodes
Roth spots
splinter hemorrhages
petechiae

Diagnosis #

Endocarditis is the inflammation of the endocardium, most commonly caused by infection, and usually affects heart valves and implanted intracardiac devices. The most common microorganisms associated with infective endocarditis (IE) are S. aureus, viridans streptococci, Strep. gallolyticus, and HACEK group organisms [1].

While IE can affect any surface of the endocardium, cutaneous findings are more commonly found in left-sided endocarditis, due to dissemination of infectious and inflammatory products into the systemic vasculature. Petechiae are the most common cutaneous manifestation of IE, 20-40% of patients experience petechiae on the extremities and mucous membranes such as the palate and conjunctivae. Other skin findings of IE include splinter hemorrhages within the nail as well as Janeway lesions and Osler nodes. Janeway lesions are more commonly found in acute IE, as they represent nontender microabscesses found on the palms and soles. Osler nodes are evidence of chronic, protracted IE, associated with immune-mediated vasculitis following microthrombotic vascular occlusion [2]. Roth spots are visible on retinal exam, and while uncommon, are relatively specific for IE [3]. Janeway lesions persist for hours to days and are not associated with resolution of IE. Other cutaneous signs of IE, such as Osler nodes, resolve over days to weeks with treatment of the underlying disease via antimicrobials targeted to the susceptibilities of the infecting organism [4].

Key Concepts #
  • Cutaneous manifestations of IE are more common in left-sided endocarditis [2].
  • Petechiae are the most common cutaneous finding in IE, and are found on the extremities and mucous membranes [2].
  • Splinter hemorrhages are a nonspecific finding in IE.
  • Janeway lesions are nontender and evidence of acute IE, while Osler nodes are tender and indicate chronic infection [2].
  • In suspected IE, first obtain blood cultures before antibiotic therapy, as well as an echocardiogram [2,5].
  • Cutaneous signs of IE resolve over hours to weeks, following initiation of antimicrobial treatment [4].
Epidemiology #

The incidence of infective endocarditis (IE) in native heart valves increased between 2000 and 2011 from 11 per 100,000 to 15 per 100,000 in the United States [6,7]. As the definition of IE has changed over time between authors and clinical locations, it is difficult to determine a very precise incidence [1]. Risk factors for IE include increasing age, male gender, IV drug use, and poor dentition [8,9]. In the United States and Europe, more than half of IE cases are in patients greater than 60 years old [8]. The male to female ratio ranges between 3:2 and 9:1 [8,10]. IV drug use is more commonly associated with right-sided endocarditis, but it is associated with 20% of left-sided cases of IE [11]. Petechiae are observed in 20-40% of patients with IE, most commonly found on the extremities and mucous membranes [2]. Janeway lesions are found in acute endocarditis, while Roth spots and Osler nodes are supportive evidence of chronic IE [2].

Clinical Features #
  • Fever is found in up to 90% of patients with IE and is often associated with chills and weight loss [2].
  • Flu-like symptoms such as arthralgias, malaise, and headache are also common in IE [2].
  • Cardiac murmurs are found in 85% of patients, specific to the valve which has been infected [2].
  • Petechiae are most commonly found on the extremities and mucous membranes such as the palate and conjunctivae [2].
  • Splinter hemorrhages are non-blanching, linear, reddish-brown lesions under the nail bed found on the fingers and toes [12].
  • Osler nodes are tender, violaceous, acral nodules found in protracted courses of IE [2].
  • Janeway lesions are nontender, erythematous macules found in acute IE [2].
  • Roth spots are exudative, hemorrhagic, edematous lesions of the retina with pale central areas [3].
Differential Diagnoses #
  • Small Vessel Vasculitis
  • Drug eruptions
  • Syphilis
  • Antiphospholipid syndrome
  • Thromboangiitis obliterans
  • Rocky mountain spotted fever
  • Coxsackie A infection
  • Dyshidrotic atopic dermatitis
Diagnostic Workup #

Diagnosis of IE is based upon the modified Duke criteria, an amalgam of clinical features, blood cultures, and echocardiography findings [2]. Definitive IE is diagnosed with 2 major criteria, 1 major and 3 minor criteria, or 5 minor criteria. Major criteria include positive blood cultures and evidence of endocardial involvement. Positive blood cultures are defined as two separate positive blood cultures with typical microorganisms, or one positive blood culture for Coxiella burnetti or IgG antibody titers greater than 1:800. Evidence of endocardial involvement includes echocardiogram positive for vegetation, abscess, dehiscence of a prosthetic valve, or new valvular regurgitation. Minor criteria include a predisposition to IE, temperature > 38°C, vascular phenomena, immunologic phenomena, and microbiologic evidence. A predisposition to IE is defined as a history of IV drug use or predisposing heart condition such as prosthetic heart valve or valvular lesion associated with regurgitation. Vascular phenomena include Janeway lesions, conjunctival hemorrhages, major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, and intracranial hemorrhage. Immunologic phenomena include glomerulonephritis, Osler nodes, Roth spots, and a positive rheumatoid factor. Microbiologic evidence as a minor criterion includes positive blood cultures that do not meet the constraints of a major criterion [13].

Any suspicion for IE should be followed by drawing blood cultures and an echocardiogram. Three sets of blood cultures should be obtained initially, each from a separate venipuncture site, as three sets detect 96-98% of bacteremia [2, 5]. As patients with IE generally have continuous bacteremia, it is not required to draw blood cultures during an episode of fever or chills, only before the initiation of antibiotics [14]. Transthoracic echocardiography (TTE) is generally recommended first for suspected IE, as the sensitivity is up to 75% and specificity approaches 100% [15]. In patients with a negative TTE and high suspicion of IE, it is generally followed with a transesophageal echocardiogram (TEE), as TEE has a sensitivity of greater than 90% for detection of valvular vegetations and for other cardiac complications [16]. These diagnostic tests paired with the clinical manifestations above provide the information necessary to diagnose IE.

Treatment #

Treatment of IE involves antimicrobial therapy. Antimicrobial therapy is generally tailored to the susceptibilities of the organism isolated from blood cultures, but initial empiric therapy is necessary for acutely ill patients. Empiric therapy should generally cover the most common organisms that cause IE, specifically covering staphylococci, streptococci, and enterococci. Duration of antibiotic therapy is determined from the first day of negative blood cultures, and generally lasts 4-6 weeks [17]. Anticoagulation has been studied and has not been shown to have a significant improvement in embolic events in patients with IE and no other indications for anticoagulation [18]. Janeway lesions generally last hours to days and will resolve without antibiotic therapy. Osler nodes and other cutaneous manifestations persist for days to weeks and resolution is associated with resolution of infection [2].

Slide Viewer #
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References #
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  2. Cahill TJ, Prendergast BD. Infective endocarditis. Lancet. 2016; 387:882.
  3. Loughrey PB, Armstrong D, Lockhart CJ. Classical eye signs in bacterial endocarditis. QJM. 2015; 108:909.
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  13. Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clinical Infectious Disease. 200; 30:633.
  14. Beeson PB, Brannon ES, Warren JV. Observations on the sites of removal of bacteria from the blood in patients with bacterial endocarditis. Journal of Experimental Medicine. 1945; 81:9.
  15. Habib G, Badano L, Tribouilloy C, et al. Recommendations for the practice of echocardiography in infective endocarditis. European Journal of Echocardiography. 2010; 11:202.
  16. De Castro S, Cartoni D, d’Amati G, et al. Diagnostic accuracy of transthoracic and multiplane transesophageal echocardiography for valvular perforation in acute infective endocarditis: correlation with anatomic findings. Clinical Infectious Disease. 2000; 30:825.
  17. Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Health Assocation. Circulation. 2015; 132:1435.
  18. Whitlock RP, Sun JC, Fremes SE, et al. Antithrombotic and thrombolytic therapy for valvular disease: antithrombotic therapy and prevention of thrombosis, 9th edition: American College of Chest Physicians evidence-based clinical based guidelines. Chest. 2012; 141:e576S.
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