Fever and macular lesions on toes

Abstract

A 50-year-old man presented to the emergency department (ED) with a 6-day history of fever and pain in his left leg. He denied any trauma and his relatives reported that he was affected by congenital idiopathic mental handicap.Positive physical findings included tooth loss and several dental caries, small erythematous macular lesions on plantar surfaces of the left toes (Fig. 1). A grade 3/6 diastolic murmur was heard over the base of the heart. Laboratory test results showed thrombocytopenia (platelet count was 44,000/lL) and a C-reactive protein concentration of 32.32 mg/dl.Deep venous thrombosis was ruled out and transthoracic and transesophageal echocardiography confirmed a severe aortic insufficiency with aortic valve vegetation of 9 mm and several nodules on all three valve leaflets. His lesions on toes were consistent with Janeway's lesions, which are present in 5 % of patients affected by infective endocarditis [1]. He underwent further evaluation with computed tomography scan showing septic embolization to the brain, spleen and kidneys. Blood cultures grew Staphylococcus aureus ss. Aureus. Systemic embolization occurs in 22-50 % of cases of infective endocarditis [1]. Asymptomatic cerebral embolism occurs in many patients: cerebral imaging is recommended in all patients with suspected infective endocarditis [2].The patient was started on intravenous gentamicin and oxacillin. His hospital stay was complicated with septic shock. Despite admission to intensive care unit, he died before undergoing cardiac surgery.