Dermatologic Conundrum: A Cardiac Condition Masqueraded as a Dermatologic Distraction

Abstract

A 38-year-old male presented to the emergency department (ED) complaining of extreme pain and a petechial rash on the left ankle for two weeks associated with generalized fatigue, intermittent fevers, and weight loss. He was discharged home from the ED on pain medications. He returned a few days later with a progressive rash that involved the entire left lower extremity to the level of the knee. He was diagnosed with herpes zoster (shingles) and was prescribed acyclovir and steroids. After several days, the patient presented for the third time to the ED. He developed a right lower extremity discomfort this time. The pain in bilateral lower extremities had become unbearable. His cardiac examination revealed a systolic murmur at the apex and a faint diastolic murmur at the left sternal border. Ultimately, he had an echocardiogram that demonstrated both a bicuspid aortic valve and large vegetation on the anterior leaflet of the mitral valve, and his blood culture grew Streptococcus mitis and Streptococcus oralis. The patient was subsequently diagnosed with subacute bacterial endocarditis thought to be sourced from his poor dentition. The diagnosis of infective endocarditis is often delayed due to its nonspecific clinical presentations. Our case displays an unusual skin manifestation of IE that may be present in the absence of other signs and symptoms of the disease.

Dermatological Changes in Patient With Infective Endocarditis

“…Embolic strokes; septic pulmonary emboli; septic arthritis; and muscular, renal, and splenic infarctions have all been noted in the IE patient with cutaneous lesions. Embolic events because of the inflammatory cascade of the disease process are the primary cause of the cutaneous lesions (Degheim et al, 2020; Josephson, 2014), Osler nodes, purpura, macula hemorrhages including cotton wool spots, splinter hemorrhages, and conjunctival hemorrhages are all examples of this embolic phenomenon (Degheim et al, 2020; Fareedy et al, 2016; Laing, 2015).…”

“…The frequency of cutaneous lesions that occur with IE can vary from 5% to 25% of the cases (Degheim et al, 2020). In addition, patients who present with cutaneous lesions associated with IE are more likely to have extracardiac complications compared to those patients who present without cutaneous lesions (Degheim et al, 2020). These extracardiac complications are often embolic in nature and can affect multiple systems.…”

“…Diagnosis of IE can be problematic and delayed especially when the patient presents with a multitude of nonspecific symptoms that could be explained by another diagnosis (Degheim et al, 2020). Because of the patient presenting with symptoms of febrile illness for 2 weeks with chills and night sweats, along with new onset nausea, vomiting, diarrhea, slurred speech, and mental confusion, the differential diagnosis for this patient included bacteremia, meningitis, cerebrovascular accident, myocardial infarction, and IE.…”

“…To promptly diagnose and manage infective endocarditis (IE), it is imperative that a thorough skin assessment is performed (Degheim et al, 2020; Laing, 2015). Because of the high morbidity and mortality rates associated with IE, early recognition and management of the disease is vital in improving prognosis and preventing complications.…”