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Original research
Diagnostic accuracy of splinter haemorrhages in patients referred for suspected infective endocarditis
  1. Ralph Schwiebert1,
  2. Wazir Baig2,
  3. Jianhua Wu3,
  4. Jonathan A T Sandoe1,4
  1. 1 Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
  2. 2 Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
  3. 3 School of Dentistry, University of Leeds, Leeds, UK
  4. 4 Leeds Institute of Medical Research, University of Leeds, Leeds, UK
  1. Correspondence to Dr Ralph Schwiebert, Department of Microbiology, Leeds General Infirmary, Leeds LS1 3EX, UK; ralph.schwiebert{at}


Objective Splinter haemorrhages are an examination finding that has classically been associated with infective endocarditis (IE), but are not included in current diagnostic algorithms. Splinter haemorrhages have not been evaluated as a diagnostic tool using modern definitions of IE. We determined their sensitivity and specificity in patients with suspected IE and investigated their inclusion in the Duke criteria.

Methods This is a retrospective diagnostic accuracy study using data from 1119 patients with suspected IE referred to the IE service. Patients were categorised according to the Duke criteria, the current diagnostic gold standard, into Duke ‘rejected’, ‘possible’ or ‘definite’ groups. Definite cases (n=451) served as the true positives and rejected cases (n=486) as the true negatives against which splinter haemorrhages were compared. Duke possible cases (n=182) were used the assess the clinical impact of adding splinter haemorrhages to the Duke criteria.

Results In clinically suspected cases of IE and using the Duke criteria as the gold standard comparator, splinter haemorrhages had a sensitivity of 26% (95% CI 22 to 31) (119 out of 451) and a specificity of 83% (95% CI 79 to 86) (403 out of 486). Inclusion of splinter haemorrhages as a minor vascular phenomenon in the Duke criteria would result in a reclassification of 12% of cases from Duke rejected to possible and 13% from Duke possible to definite.

Conclusion Splinter haemorrhages are an insensitive tool in the diagnosis of IE, but their high specificity indicates they do have clinical value in patients with suspected infection. Their inclusion in the Duke criteria as a minor vascular criterion reduces diagnostic uncertainty for some Duke possible cases, while increasing it for a similar proportion of Duke rejected cases.

  • Endocarditis

Data availability statement

Data are available upon reasonable request. Anonymised data of the domains analysed here can be provided upon reasonable request.

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Data availability statement

Data are available upon reasonable request. Anonymised data of the domains analysed here can be provided upon reasonable request.

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  • Contributors RS and JATS developed the conceptual design of the study. JATS and WB collected clinical data. RS performed data analysis and wrote the manuscript. JATS and WB critically reviewed the manuscript. JW aided with statistical test selection and interpretation. RS is responsible for the overall content as the guarantor.

  • Funding RS is supported by a National Institute of Health Research academic clinical fellowship. In the last 5 years, JATS has received research funding from MRC, EPSRC, NIHR, Wellcome, Astellas, Pfizer, MSD and Lumos. JATS has received funding for educational events from Tillotts Pharma.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.