Janeway lesions in infective endocarditis

Janeway lesions are one of the stigmata of infectious endocarditis. They are irregular, erythematous, flat, painless macules on the palms, soles, thenar and hypothenar eminences of the hands, tips of the fingers, and plantar surfaces of the toes; they rarely present as a diffuse rash, and are very rare in clinical practice.

A 25 year old woman presented with prolonged fever. She was on regular penicillin prophylaxis for rheumatic mitral valve disease. She had fever at the time of presentation. Her physical examination revealed erythematous macular painless rashes distributed along the thenar and hypothenar eminences of both hands (panel A), which were more pronounced on the left hand (panel B). She had subconjunctival haemorrhages and subungual splinter haemorrhages. Cardiac examination revealed moderate mitral regurgitation and mild mitral stenosis. She also had hepatosplenomegaly.

The diagnosis of infective endocarditis was confirmed by blood cultures, which grew Streptococcus viridans in three separate cultures, and echocardiographic demonstration of vegetation attached to the mitral valve (panel C).

The patient was treated with intravenous antibiotics (crystalline penicillin and gentamicin).