Janeway Lesions Research Articles

An unusual presentation of subacute Haemophilus parainfluenzae endocarditis in a low-risk woman treated by minimally invasive mitral valve repair: a case report

BackgroundHACEK endocarditis is usually insidious and can often be difficult to diagnose due to the slow-growing nature of the organisms. This report presents our experience in treating a patient with Haemophilus parainfluenzae endocarditis.Case presentationWe describe the case of a previously fit and well 23 year-old woman who presented to her local emergency department with a four-week history of persistent febrile illness. She had associated nausea, vomiting, and lethargy. This was preceded by an episode of mucopurulent rhinorrhoea. She was treated empirically with oral amoxicillin for a putative diagnosis of rhinosinusitis. Initially, her symptoms abated, however, she was readmitted with high fevers and a new pansystolic murmur. Transthoracic echocardiography revealed a large, mobile, echogenic mass, tethered to the posterior mitral valve leaflet (PMVL) and mild mitral regurgitation (MR). On examination, she had multiple non-tender, erythematous macules on the plantar surface of her feet, consistent with Janeway lesions. Two separate blood cultures grew H. parainfluenzae. Infectious diseases recommended a four-week course of intravenous ceftriaxone. Transesophageal echocardiography demonstrated a perforation within the P3 segment of the PMVL. Subsequently, the patient underwent mitral valve repair surgery with an uneventful recovery.ConclusionsOur case highlights the importance of promptly diagnosing HACEK endocarditis. A prolonged course of antibiotic therapy can be lifesaving, and surgery is often necessary to address complications such as perforation within the mitral valve leaflets. In our patient, we were able to perform a sliding P2 leaflet plasty for good quality repair of the mitral valve, through a minimally invasive right anterior thoracotomy.

A late-onset leg rash, unique Janeway lesions or Jarisch-Herxheimer reaction? A case report

Jarisch-Herxheimer reactions typically manifest as a response to antimicrobial therapy for spirochete infections, although these reactions have also been documented following treatment of other microbes. Almost always occurring within 24 hours of treatment initiation, Jarisch-Herxheimer reactions can cause hypotension, fevers, chills, headaches, myalgia, skin rashes, and exacerbations of existing skin lesions, among others; the most feared complication from such reactions is shock. They are usually transient and self-limiting but can cause significant discomfort and concern for patients. Treatment is usually supportive, consisting mostly of nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, and intravenous fluids. Reactions with delayed onset are exceedingly rare, and to our knowledge, have been documented only one other time in literature. In this clinical vignette, we present a case in which a patient developed what we initially suspected to be Janeway lesions; however, the presence of systemic symptoms suggest that what was observed was delayed-onset Jarisch-Herxheimer reaction 16 days after initiation of antibiotics.

The Right Time for Certification

The Right Time for Certification

Janeway Lesions as a Manifestation of Aortic Graft Abscess

A 39-year-old man with history of intravenous drug use presented with fevers and back pain. Physical examination revealed multiple painless, small, hemorrhagic macules on the left plantar surface consistent with Janeway lesions. Janeway lesions were likely secondary to embolic sequelae of infected aortic graft without evidence of classical endocarditis, as vegetations were excluded on transesophageal echocardiogram.

PS-R05-5: A CASE OF SEPTIC PULMONARY EMBOLISM DUE TO MITRAL VALVE ENDOCARDITIS OCCURRING EARLY IN THE INDUCTION PHASE OF HEMODIALYSIS

A 66-year-old man with end-stage kidney disease (ESKD) due to chronic glomerulonephritis who was scheduled to start hemodialysis after surgery for radiocephalic arteriovenous fistula (AVF) was admitted to our hospital because of volume overload. He developed fever and cough after an upper endoscopy was performed on the 20th hospital day. Chest CT revealed an infiltrative shadow in the right lower lung and he was diagnosed with bacterial pneumonia and treated with sulbactam/ampicillin and azithromycin. Two sets of blood cultures were negative. There were no findings suggesting infection of the AVF. His fever persisted and repeated CT on day 37 showed multiple nodule shadows along the blood vessels in the left lower lobe. We suspected septic pulmonary embolism (SPE) and transthoracic/esophageal echocardiography showed a newly developed MV regurgitation (MVR (II/IV), with a 17 mm vegetation and partial perforation. Repeat physical examination revealed nontender, small erythematous (Janeway) lesions on the toes and a new holosystolic murmur at the apex (II/VI). (The patient said he had similar lesions on his hands but they had disappeared.) Due to the accumulation of Ga-67 citrate in the peri-oral area and the MV, caries and periodontal disease were thought to be the source of infection. Infectious endocarditis (IE) was diagnosed based on modified Duke criteria. Ceftriaxone was added to cover gram-negative bacilli in the oral cavity, including HACEK (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella). Antibacterial treatment reduced the size of the vegetation and the MVR improved. Pulmonary nodules also disappeared. Dental treatment was performed after the vegetation had almost disappeared. Three additional sets of blood cultures were also negative. There have been few reports of SPE due to left sided IE. The onset of SPE in this case may have been caused by an embolus that formed in the MV and flowed into the right sided heart via an AVF, as emboli were also found in the peripheral extremities.

Abstract 10249: Infective Endocarditis: A Diagnostic Challenge

Case: A healthy 30-year-old female with past medical history of eczema and no prior cardiac history presented with altered mental status, fever, neck stiffness and photophobia. Blood and CSF cultures grew methicillin susceptible Staphylococcus aureus , and the patient was started on nafcillin and linezolid. Bacteremia source was unclear, presumed to be minor skin breaks on her hands. MRI brain revealed multiple cerebral septic emboli, prompting concern for infective endocarditis. However, TTE and TEE were negative for vegetations, valve thickening, and valvular regurgitation. Blood cultures remained positive for MSSA despite dual antibiotic therapy and by hospital day 4, she began experiencing shortness of breath and new Janeway lesions were noted on exam. Repeat TTE and TEE were also negative for endocarditis. To further evaluate for an arterial source of seeding, CTA chest/abdomen was obtained which was unremarkable. Given persistence of bacteremia despite dual antibiotic therapy and unknown left-sided source, whole body PET CT scan was obtained which showed focal FDG uptake in the mitral annulus/valve region. Repeat TEE the following day showed a mitral valve ring abscess, a 1.2x0.4cm vegetation involving the P3 segment of the mitral valve, perforation at the mitral valve annulus, and new moderate mitral regurgitation. After a risk benefit discussion, the patient opted for conservative management with serial monitoring over surgical repair. She was treated with six weeks of nafcillin and four weeks of linezolid. Most recent TEE showed resolution of valvular abscess and vegetation with continued moderate mitral regurgitation. Discussion: We present a case of high grade MSSA endocarditis in a young, healthy patient without pre-existing valvular disease, causing mitral valve perforation. Infective endocarditis remains a challenging diagnosis, and this case highlights the diagnostic utility of FDG PET CT scan in such complex cases.

Dermatological Changes in Patient With Infective Endocarditis

ABSTRACT This is a case study of a 69-year-old man who presented with fever of unknown origin, nausea, vomiting and diarrhea, confusion, and expressive aphasia with multiple dermatological abnormalities, including Osler nodes, Janeway lesions, petechia on conjunctiva of eyes, and splinter hemorrhages underneath the nails. After further assessment, the patient was diagnosed with infective endocarditis.

Osler´S Nodes and Janeway Lesions: From Clinic to Diagnosis

Osler´S Nodes and Janeway Lesions: From Clinic to Diagnosis

Cutaneous Manifestations of Infective Endocarditis

Despite advances in diagnosis and treatment, infective endocarditis still shows considerable morbidity and mortality rates. The dermatological examination in patients with suspected infective endocarditis may prove very useful, as it might reveal suggestive abnormalities of this disease, such as Osler’s nodes and Janeway lesions. We report a case of a women with infective endocarditis and the typical cutaneous manifestations. Despite advances in diagnosis and treatment, infective endocarditis still shows considerable morbidity and mortality rates. The dermatological examination in patients with suspected infective endocarditis may prove very useful, as it might reveal suggestive abnormalities of this disease, such as Osler’s nodes and Janeway lesions. We report a case of a women with infective endocarditis and the typical cutaneous manifestations.

Covid-19 And Infective Endocarditis - The Challenge of the 21st Century

COVID-19 can cause multiple organ dysfunction including cardiovascular system that affects the course and prognosis of disease. We present a case of a 65-year-old man with a history of arterial hypertension and severe COVID-19 complicated with acute pneumonia, acute respiratory distress syndrome, septic shock, infective endocarditis, severe stenosis and regurgitation of aortic valve, spontaneous pneumothorax and acute kidney failure. Chest CT scan included bilateral lung involvement with subtotal ground-glass opacities and consolidations. Lung injury was considered as H type. Echocardiography revealed hyperechogenic formation (5mm in size) - vegetation on the right coronary cusp of aortic valve, that caused sever stenosis and regurgitation. On the extremities Janeway lesions and Osler's nodes were revealed. He became hemodynamically unstable. Besides leukocytosis, neutrophilia with a left shift, lymphopenia, eosinopenia, moderate thrombocytopenia and deep anemia, high level of CRP, procalcitonin and severely increased D-Dimer (83600 µg/L) was notable. In spite of adequate treatment with dexamethasone, antibiotics and anticoagulants patient developed first left sided and lately right sided complete spontaneous pneumothorax and was connected to mechanical ventilation. Though after thoracentesis and air evacuation from pleural cavities both lungs were expanded patient’s state remained critical. Patient developed septic shock, acute renal failure, acute cardiovascular and respiratory insufficiency and lethal outcome was defined. Presented case shows that COVID-19 causes different kind of multiple organ dysfunction that determines the outcome of the disease. It is important to follow and monitor the patients not only in critical and sever but in mild or common cases as well.

Development, production and evaluation of 2-dimensional transfer tattoos to simulate skin conditions in health professions education

BackgroundMoulages can greatly extend the possibilities of simulation in teaching and assessment. Since moulages that fit an educator’s exact needs are often unavailable commercially, this paper explains how 2-dimensional transfer tattoos can be independently developed, produced, and evaluated.MethodsFrom representative photographs of the specific skin condition an analogue copy of the pathological finding is drawn. Once validated by the medical expert, it can be digitized by scanning and processed using graphics software. The final digital image file is printed onto transfer paper. Once applied and fixed onto the intended wearer, usually a simulated patient, its authenticity can be confirmed, and further transfer tattoos can be produced.ResultsUsing this moulage technique we produced 10 different 2-dimensional transfer tattoos to date, including hematoma, Janeway lesions and splinter nails. These moulages are used in clinical skills training, formative and high-stakes summative assessment in undergraduate medical and nursing programs.ConclusionsBy sharing our development process for 2-dimensional transfer tattoos, health profession educators can produce their own that best fit their local educational needs. Due to their high authenticity and standardization, 2-dimensional transfer tattoos are ideal for use in high-stakes assessment.

A RARE CASE OF INFECTIVE ENDOCARDITIS FOLLOWING CORONARY ANGIOPLASTY WITH AN UNUSUAL PRESENTATION OF ENDOPHTHALMITIS

Objective: There is a rise in the global incidence of infective endocarditis due to gram-negative bacilli like Pseudomonas aeruginosa and involving structures of the left side of the heart such as valve apparatus and papillary muscles. It is due to the increasing usage of implantable cardiac devices and prosthetic valves. Occurrence of infective endocarditis following minor cardiac procedures like coronary angiography or angioplasty is extremely rare. Infective endocarditis has varied clinical presentations making its diagnosis difficult. Hence a high degree of clinical suspicion by the treating physician is essential for rapid diagnosis and treatment. Design and method: We present a case of a 54 year old man, a non-intravenous drug user with long standing history of diabetes mellitus, who underwent a per-cutaneous coronary angioplasty for a double vessel block of the coronary vasculature. Six months later he presented to the emergency room with a febrile illness. His initial blood report was positive for dengue fever. His clinical symptoms rapidly worsened over one day with development of endogenous endophthalmitis of left eye, erythema nodosum, new-onset Janeway lesions and transient glomerulonephritis. Blood and vitreous fluid cultures showed growth of Pseudomonas aeruginosa. Results: Transthoracic echocardiogram showed presence of an oscillating vegetation attached to the papillary muscle of the left ventricle, associated with moderate mitral regurgitation and new onset mitral valve prolapse. He was aggressively treated with a combination therapy of intravenous and intravitreal antibiotics. His clinical features and blood hemogram showed gradual improvement over the next four weeks, responding to medical treatment. Echocardiogram was repeated which showed no resolution in findings. As his visual acuity showed no improvement, an enucleation surgery of his left eye was planned. One day prior to the surgery, patient became unresponsive with no recordable pulse rate and blood pressure. He had developed a sudden cardiac arrest and died. Conclusions: Complications and systemic embolization are more commonly associated with the left heart infective endocarditis. Despite various advances and administration of adequate treatment, infective endocarditis is associated with a guarded prognosis. It has significantly high degree of morbidity and mortality.

FAME: A Resident's Reflection on a Tanzania Medical Trip

Residents' Review| March 2021 FAME: A Resident's Reflection on a Tanzania Medical Trip Margaret Chiu, MD Margaret Chiu, MD Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor March 2021, Vol. 85, 29. https://doi.org/10.1097/01.ASM.0000737104.11746.18 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Share Icon Share Facebook Twitter LinkedIn Email Cite Icon Cite Get Permissions Search Site Citation Margaret Chiu; FAME: A Resident's Reflection on a Tanzania Medical Trip. ASA Monitor 2021; 85:29 doi: https://doi.org/10.1097/01.ASM.0000737104.11746.18 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search nav search search input Search input auto suggest search filter All ContentAll PublicationsASA Monitor Search Advanced Search Topics: fingolimod-associated macular edema, tanzania A teenage boy sat in the shade of the emergency department, his shoulders draped with a red plaid sheet. His feet sported distinctive Maasai sandals cut from old tire treads. He had been an inpatient of the hospital long before my arrival. My first time caring for him in the OR was for a washout of his septic knee. He had dark spots on the soles of his feet: Janeway lesions. My brain dug up this telltale sign for endocarditis that I diligently memorized in medical school – just one of many instances in Tanzania where I encountered something that I had previously only read about. Despite rounding on him daily and providing anesthesia for him on multiple occasions, I had maintained my distance. Instead of making an effort to connect, I busied myself with academic pursuits. I had... © 2021 American Society of Anesthesiologists (ASA), All Rights Reserved.2021 You do not currently have access to this content.

Clinical presentation and outcome of infective endocarditis

Despite the decline in rheumatic heart disease worldwide and the use of antibiotic prophylaxis, there is no evidence that the incidence of infective endocarditis (EI) is decreasing. In fact, some data suggestit may be increasing. The classical fever of unknown origin presentation represents a minority of EI cases today; thus, clinicians need to be vigilant about keeping EI in mind with some of these more unusual presentations The aim was to study various presentations of EI, which are organized into three groups of presenting symptoms and signs: nonspecific, cardiac, and embolic This was a descriptive retrospective study of 62 patients hospitalized in Charles Nicolle hospital and treated for definite EI from 2011 to 2019. The mean age of patients was 50.12 ± 16.66 years ranging from the age of 19 and 88 years. The study population consisted of 35 men (57.1%) and 27 women (42.9%). 44 (89.9%) of the patients had been admitted due to fever. Peripheral signs like Janeway lesion and Osler's node were not seen, arthralgia was seen in 9 patients. Heart failure was observed in 30.6% of the cases. Embolic events were common: stroke (18.3%), pulmonary emboli (9%), peripheral vascular emboli (10.2%) and spleen infarction (14.2%). After instauration of the treatment most complication were cerebral (6%), spleenic (7%), cardiac (10%), thirty two of the patients improved and were discharged in good general condition. Seven patients died, and in hospital mortality of 14.3%. EI is a disease in which the presentation are various and acute than previously described and remains a serious and deadly disease despite recent advances in diagnosis and treatment.

Janeway lesion and infective endocarditis.

Infective endocarditis (IE) is defined as infection of the endocardial surface of the heart which may involve heart valve, mural endocardium or septal defect. It's a disease with high morbidity and mortality without prompt treatment with antibiotics. Janeway lesions, Osler's node and splinter hemorrhages are the classical signs of infective endocarditis described previously. However, these signs are not commonly seen nowadays. In this present paper, we would like to illustrate a case of IE with typical Janeway lesions.

A Case of Pediatric Cerebral Hemorrhage Complicated with Infective Endocarditis

The mortality rate associated with cerebral hemorrhage as a complication of IE is extremely high despite the development of preventive and antibiotic therapy. We report a 13-year-old female whose previous medical history includes Jeune syndrome and mitral regurgitation. She was taken to a nearby hospital because of high body temperature. She had no symptoms of cold or gastrointestinal disturbance and was diagnosed with upper respiratory tract inflammation. On the subsequent day, she experienced a seizure and was brought to the emergency department of the general hospital. Her head computed tomography (CT) revealed bleeding and mild cerebral edema in the left occipital lobe. A mild systolic murmur was audible upon auscultation. She presented with carious tooth and Janeway lesions. Methicillin-resistant <i>Staphylococcus aureus</i> (MRSA) was positive on blood culture examination, cerebrospinal fluid examination was negative. A diagnosis of IE was established based on the Duke criteria. Antibiotic therapy was administered. Thereafter, the symptoms disappeared without any adverse effects, and antibiotic administration was ended in six weeks. After the discharge, dental treatment was initiated. There was no recurrence of IE at 3 years after the onset, and no sequelae were observed. Although the prevalence of cerebral hemorrhage as a complication of IE is low, the associated mortality rate is extremely high despite the development of preventive and antibiotic therapy. Moreover, there is no consensus regarding the treatment method. In this case, only a conservative treatment was performed without sequelae. Pediatric patients with stroke associated with IE may have better outcome than adults. It is important to suspect IE and to provide immediate or early treatment if fever and central nervous symptoms are observed in cases with underlying heart disease.

Infective Endocarditis of Patent Foramen Ovale Closure Device Presenting as an Amoeboid-Like Mass

A 73-year-old woman presented with fever and Janeway lesions on her palms. She had undergone transcatheter patent foramen ovale closure with a 30-mm Amplatzer Cribriform device (Abbott, Chicago, Illinois) 6 years before. Two months before onset, she had received dental procedures without antibiotic

A Rare Case of Corynebacterium Endocarditis

A 26-year-old gentleman presented with a 1-month history of fevers, malaise and weight loss. He was born in China and had moved to Australia during his childhood. He was appropriately vaccinated. There was no history of recent dental procedures or illicit drug use. On examination, the temperature was 39 °C. Heart rate, blood pressure and oxygen saturations were normal. There was a pan-systolic murmur over the apex. There were small, non-tender, erythematous macules over both palms consistent with Janeway lesions. Neurological examination was unremarkable. Blood tests revealed raised inflammatory markers (C-reactive protein 87 mg/L). Four separate sets of blood cultures at admission isolated Corynebacterium pseudodiphtheriticum, sensitive to penicillin. Urgent transthoracic echocardiography revealed a large vegetation (11 × 9 mm) attached to the anterior mitral leaflet with associated moderate-severe regurgitation. Left ventricular function was preserved. The patient was commenced on empirical therapy for endocarditis, subsequently rationalised to intravenous benzylpenicillin. Embolic workup revealed multiple cerebral lesions suspicious for mycotic aneurysms and a small subacute infarction in the right frontal lobe. He underwent mechanical mitral valve replacement after 2 weeks of intravenous antibiotic therapy. Valve tissue and subsequent blood cultures were negative and the patient was discharged home following a 6-week admission.

Image of the month: ‘Diagnostic hands’: Janeway lesions

Dermatologic lesions can reflect cutaneous manifestations of systemic diseases thus furnishing clues for a precise diagnostic hypothesis. In the present case, the appearance of fever and reddish lesions on the palms of both hands led the patient to seek medical consultation. The patient was a 30-

Neurological Complications in Eosinophilic Granulomatosis with Polyangiitis (EGPA): The Roles of History and Physical Examinations in the Diagnosis of EGPA.

Objective To investigate the clinical symptoms, the physical and neurological findings, and the clinical course of neurological complications in eosinophilic granulomatosis with polyangiitis (EGPA). Methods A retrospective chart review of EGPA cases managed by two referral hospitals was performed, with a focus on the neurological findings. The study analyzed the symptoms at the onset of EGPA and investigated their chronological relationship. The patient delay (the delay between the onset of symptoms and the initial consultation), and the physician delay (the delay from consultation to the initiation of therapy) were determined and compared. The involved nerves were identified thorough a neurological examination. The cases with central nervous system (CNS) involvement were described. Results The average duration of symptoms prior to the initiating of therapy for sensory disturbances, motor deficits, rash, edema, and fever was 23, 5, 21, 18, and 24 days, respectively. Among the EGPA-specific symptoms, sensory disturbance was often the first symptom (63%), and was usually followed by the appearance of rash within four days (63%). The average physician delay (32.9±38.3 days) was significantly longer than the average patient delay (7.9±7.8 days; p=0.010). Reduced touch sensation in the superficial peroneal area, and weakness of dorsal flexion of the first toe secondary to deep peroneal nerve involvement, were highly sensitive for identifying the presence of peripheral nerve involvement in our series of patients with EGPA. Two cases, with CNS involvement, had multiple skin lesions over their hands and feet (Janeway lesions). Conclusion Japanese physicians are not always familiar with EGPA. It is important for us to consider this disease, when an asthmatic patient complains about the new onset of an abnormal sensation in the distal lower extremities, which is followed several days later by rash.