Janeway Lesions Research Articles

TL; DR (too long; didn't read) medicine and pocket‐sized textbooks

Studying medicine in the internet age is fascinating, daunting and depressing. Fascinating because we can instantly YouTube anything — from clinical examinations and suturing techniques to recordings of laparoscopic surgery and lectures on any topic imaginable — and at any time. We can Google image-search anything from Janeway lesions and Roth spots to erythema nodosum and pancreatic panniculitis, granting us a wealth of experience in a mouse click.

Endocarditis Caused by Actinobaculum schaalii, Austria

Endocarditis Caused by Actinobaculum schaalii, Austria

Janeway lesions with inconspicuous histological features

Septic-embolic diseases are life threatening; survival critically depends on rapid diagnosis. Clinically, cutaneous manifestations like Janeway lesions are infrequently occurring but highly characteristic. In contrast, histological features are not clearly defined. We report the case of a 59-year-old male patient in deteriorating general condition and fever of unknown origin with lesions suggestive for Janeway lesions. Histology showed dilated blood vessels and extravasated erythrocytes throughout the dermis. Only serial sections revealed single, deep dermal vessels occluded by fibrin thrombi. Computed tomography scan identified multiple pulmonary round masses. Blood cultures showed growth of Staphylococcus aureus and Enterococcus faecalis. The knowledge of the described subtle histological features and a clinical-pathological correlation is essential for the diagnosis of certain cases of septic-embolic conditions.

Osler’s Nodes and Janeway Lesions

Osler’s nodes and Janeway lesions are 2 legendary signs associated with endocarditis. However, there are surprisingly few good illustrations of these 2 signs, and there is much confusion about their pathophysiology.

Extracardiac Manifestations of Infective Endocarditis and Their Historical Descriptions

In his landmark "Gulstonian Lectures on Malignant Endocarditis," published in 1885, William Osler commented, "Few diseases present greater difficulties in the way of diagnosis than malignant endocarditis, difficulties which in many cases are practically insurmountable." At that time, the fields of microbiology and blood cultures were in their infancy, and the diagnosis was made premortem in just half the patients with the condition. After Osler's report, extracardiac physical findings became essential clues to earlier diagnosis. Today, infective endocarditis is most commonly suggested from the history and often clinched by an echocardiogram and blood cultures. Although prized physical manifestations are much less frequent now, they still do occur and may be an invaluable clue that leads to earlier, more effective treatment. The investigators review these extracardiac findings along with their historical descriptions: splinter hemorrhages, emboli, Osler's nodes, Janeway and Bowman lesions of the eye, Roth spots, petechiae, and clubbing.

Osler's nodes and Janeway lesions

The pathogenesis of Osler's nodes and Janeway lesions remains a mystery despite vigorous debate over the last 113 years. They are given great emphasis among the clinical signs of bacterial endocarditis but are seldom seen in practice. Two cases of subacute bacterial endocarditis are presented. A 66-year-old woman with Bartonella henselae endocarditis developed Osler's nodes on the hands postoperatively, and a 23-year-old man with Streptococcus oralis endocarditis developed tender macules with an appearance suggestive of Janeway lesions on one heel. The dermatopathology was similar in the two cases, consisting of a leukocytoclastic vasculitis without micro-abscess formation or visible organisms. Although the appearance is usually consistent, it is not always possible to distinguish Osler's nodes from Janeway lesions based purely on clinical presentation. Furthermore, the histology of both clinical signs can look similar. Further reports are needed before more firm conclusions can be drawn, however, it may be that the histological appearance of Osler's nodes and Janeway lesions is primarily determined by the nature of the causative organism, while the clinical appearance may be determined by anatomical site.

61-Year-Old Woman With Knee Pain and Confusion

61-Year-Old Woman With Knee Pain and Confusion

Presence of concomitant asymptomatic and symptomatic emboli resulting from acute staphylococcus aureus endocarditis

A 25-year-old male intravenous heroin user with Hepatitis C presented with a syncopal episode and left sided weakness. Examination revealed sub-conjunctival hemorrhages and diffuse bilateral petechiae on his lower extremities. He had multiple irregular, erythematous, painless macules on his hands and feet, and linear, red, subungal lesions bilaterally. These findings were consistent with Janeway lesions and splinter hemorrhages, respectively. His vital signs were stable on admission. Cardiac auscultation revealed a grade 2/6 holosystolic apical murmur radiating to the axilla. A brain MRI revealed multiple areas of hyperdensity, particularly in the right parietal lobe (Figure 1). Blood tests revealed leukocytosis and six of six blood cultures yielded methicillin sensitive Staphylococcus Aureus. The patient was treated with intravenous nafcillin and gentamicin.

Fatal subclavian stent infection remote from implantation

We report the unusual case of a 66-year-old alcoholic male who presented with acute arm ischemia 4 months following ipsilateral subclavian artery stenting. The patient had a petechial rash and Janeway lesions in the distribution of the affected subclavian artery. He had been treated for an infected dialysis graft 10 days prior to entry into the hospital. Subsequent angiogram confirmed a patent stent with intraluminal filling defects and occlusion of the brachial artery. Thrombectomy yielded material that was consistent with septic emboli and CT scan of the chest was suggestive of a mycotic aneurysm around the stent. The subclavian stent was removed surgically and the aneurysm was repaired. Unfortunately, the patient had multiple comorbidities and died of complications during recovery. This is the first case of a subclavian stent infection following septicemia remote from implantation.

Staphylococcus capitis Endocarditis

Staphylococcus capitis Endocarditis

Cunninghamella bertholletiae Endocarditis

Cunninghamella bertholletiae Endocarditis

Mortality predictor parameters in infective endocarditis

While the death rate associated with infective endocarditis (IE) remains high, the parameters for predicting mortality are poorly defined. Through a retrospective study of 100 patients with IE based on Duke criteria, our group evaluated the clinical and echocardiographic factors that most strongly correlate with intrahospital mortality. The study included patients with native valves and prosthetic valves as well as patients with congenital cardiac disease. The results were obtained using the chi-square and Fisher exact tests. We observed a positive relation between mortality and age (P = 0.005), anemia (P = 0.047), neurological events (P = 0.0006), Janeway lesions (P = 0.0032), number of abnormalities on echocardiography (P = 0.047) and a tendency for a higher mortality related to cardiac heart failure (P = 0.105), renal insufficiency (P = 0.093), arthritis (P = 0.063), mitral valve involvement (P = 0.062), surgical indication (P = 0.076), and cardiac abscess (P = 0.081). In conclusion, age, anemia, neurological events, number of echocardiographic abnormalities and Janeway lesions are strongly correlated with an increased mortality risk. The presence of cardiac heart failure, renal insufficiency, arthritis, mitral valve involvement, abscess and surgical indication show a tendency for the same correlation.

Non-smoker with pulmonary nodules

A 57-year-old man was admitted to the hospital in May because of fever, night sweats, cough, dyspnea, and multiple pulmonary nodules. He had non-insulin dependent diabetes and had been in his usual state of health until three months before admission, when he was successfully treated with a six-week course of antibiotics for right foot osteomyelitis. One month before admission, he was treated for a dry cough and dyspnea, attributed to worsening congestive heart failure. Five days before admission, he developed fever, night sweats, dry cough, pleuritic chest pain, but no hemoptysis. Over the past six months, he had lost 30 pounds. He was admitted for workup. Antibiotics were not started. The patient was a married, black, retired handyman/ doorman with a past history of diabetic retinopathy, CHF, mitral regurgitation, remote CVA with residual left facial droop. There was no history of recurrent sinusitis. His medications included furosemide, captopril, digoxin, glyburide, lovastatin, ranitidine, and oxycodone. He was born in New York City and had spent most of his life in New York, except 20 years ago, when he lived in Western Texas for three to four months. He had not traveled outside of North America.There was no history of tobacco use, drug use, alcohol abuse, HIV risk factors, asbestos exposure, or undercooked seafood ingestion. He did not have pets or unusual bird exposure. On examination, the temperature was 100.6”F, blood pressure 150/80 mmHg, pulse 92/min, and respiratory rate 20/min. Fundoscopic examination revealed diabetic retinopathy, but no evidence of endophthalmitis. No adenopathy was found. Jugular venous distention was elevated at 10 cm. There were bibasilar crackles and pedal edema. Oxygen saturation was 96% on room air. No clubbing was noted. There were no murmurs, Osler nodes, Janeway lesions, splinter hemorrhages, subconjunctival hemorrhages, or Roth spots. There was

Cases from the Osler Medical Service at Johns Hopkins University

Presenting featuresA 57-year-old man was seen because of an acutely painful middle finger. For 2 months he had had intermittent pain and numbness in the fingers of both hands that led him to stop operating a printing press at work. His medical history was remarkable only for a 40-year history of cigarette smoking. He was afebrile. Examination revealed an exquisitely tender third finger, cool beyond the proximal interphalangeal joint, with rubor and distal pallor (Figure 1). This and other digits demonstrated nailbeds with splinter hemorrhages (Figure 2). No Janeway lesions or Osler nodes were noted. Pulses were intact at the wrist. The results of initial routine laboratory tests, including an erythrocyte sedimentation rate, were normal. Transesophageal echocardiography revealed no source of embolization.What is the diagnosis?

Appendix TOAST Abstraction Manual TOAST Medical Record Abstraction Manual

Appendix TOAST Abstraction Manual TOAST Medical Record Abstraction Manual

Right-sided pulmonary oedema

A 68-year-old man was admitted to hospital in December, 1997, 3 days after acute onset of chest pain, progressive exertional dyspnoea, haemoptysis, and fever. His medical history was otherwise unremarkable. On examination he was in moderate distress. His temperature was 38°C, pulse 120/min, blood pressure 140/80 mm Hg, and respiration rate was 28/min. On auscultation of his chest there were crepitations over the right lung and a pansystolic murmur at the cardiac apex. There were no splinter haemorrhages, Roth spots, or Janeway lesions. Routine laboratory findings were within normal limits except for a white blood cell count of 11·2 × 109/L, erythrocyte sedimentation rate of 84 mm/h, and C-reactive protein of 207 mg/L. Culture of blood specimens and serological testing were negative. Chest radiography (figure) and computed tomography showed alveolar infiltrates located predominantly in the right upper lobe, where traces of blood were detected by fibreoptic bronchoscopy.

Septic microemboli in a Janeway lesion of bacterial endocarditis

Septic microemboli in a Janeway lesion of bacterial endocarditis

The identification of methicillin-resistant Staphylococcus aureus in Osler's nodes and Janeway lesions of acute bacterial endocarditis

The pathogenesis of Osler's nodes and Janeway lesions has been disputed since their first description more than 100 years ago. Hypersensitivity vasculitis has been suggested, whereas others have sought to prove that septic microemboli are the cause. Little histologic evidence has been provided, however, to confirm the suspicion that the skin lesions in acute bacterial endocarditis are secondary to septic emboli. We describe a patient with fulminant methicillin-resistant Staphylococcus aureus endocarditis and skin lesions that cultured the same organism. Histologic examination revealed gram-positive cocci in clusters and chains within the lumen of vessels.

Infected Arteriovenous Hemodialysis Graft Presenting as Left and Right Infective Endocarditis

Prosthetic grafts have become an acceptable alternative to the autogenous arteriovenous dialysis fistula. The major drawback in their use for the dialysis patient is infection. We present a case of infected polytetrafluoroethylene arteriovenous fistula (endarteritis) with signs of unilateral splinter hemorrhage, Janeway lesions in the affected limb and septic venous embolization to the lungs. The graft eventually ruptured requiring emergency surgery. Staphylococcus aureus is by far the most common implicated organism. An otherwise non-threatening infection at a fistula site can lead to more serious complications such as infective endocarditis.

Septic emboli from a radial artery catheter with local manifestations of subacute bacterial endocarditis

Septicemboli, giving rise to physical signs similar to those of subacute bacterial endocarditis, are extremely rare complications of radial artery catheterization. A case is reported with splinter hemorrhages and Janeway lesions, resulting from an infected radial artery catheter. Five other cases with these signs are collected from among 21 patients with localized septic complications described in the literature. The duration of radial artery catheterization was 4 days or longer in all cases, and Staphylococcus aureus was the offending agent in all. We conclude that arterial lines should be removed as early as possible, and in any case they should be pulled out at the earliest sign of a local complication. In the presence of signs of local infection, antistaphylococcal treatment should be given until results of cultures are available.