Cutaneous Infarct and 4-Week Fever in a Young Man.

Sir,

A 34-year-old man presented to us with a history of high-grade intermittent fever for the preceding 4 weeks. It was associated with a few painful skin eruptions on his toes. On further query, he gave a history of mild exertional breathlessness for the last 7 days. There was no past history suggestive of any systemic illness including rheumatic fever. He had no addiction. Cutaneous examination revealed a few black, irregularly shaped, necrotic, tender, and slightly depressed lesions on the tips of several toes [Figure 1a]. There was no other mucocutaneous change. On examination, his pulse rate was 110/min, regular and blood pressure was 120/70 mm Hg. He had mild pallor but there was no clubbing or edema. Jugular venous pressure was normal. Cardiovascular examination revealed features of mitral stenosis, mitral regurgitation, and aortic regurgitation. Systemic examination and ocular examination was otherwise normal. Complete hemogram revealed leucocytosis (21,000/cmm) with neutrophilia (80%). Biochemical panel including urine examination was within normal limit. Echocardiography showed moderate valvular mitral stenosis, mild mitral regurgitation, and moderate aortic regurgitation. In addition, there were two vegetations [Figure 1b–d]. One of them was attached with the mitral valve (8 mm × 6 mm) and the other with the aortic valve (6 mm × 5 mm). Computed tomographic scan of the brain revealed normal study. Based on the findings, a diagnosis of sub-acute bacterial endocarditis was made. Initially, we empirically started intravenous ceftriaxone 2 g/day. Later, blood culture grew out Staphylococcus aureus which was also sensitive to ceftriaxone. Within a couple of weeks, his symptoms subsided and vegetations gradually decreased in size and we continued the treatment up to 4 weeks.

Figure 1

(a) Cutaneous infarcts on toes (b) echocardiograpghy (parasternal long axis view) showing vegetation attached with mitral valve (c) echocardiograpghy (apical four chamber view) showing vegetation attached with mitral valve (d) echocardiograpghy (parasternal long axis zoomed view) showing vegetation attached with aortic valve

Infective endocarditis (IE) carries a high risk of morbidity and mortality. Rapid diagnosis, appropriate treatment, and prompt recognition of complications are extremely important for better patient outcome.[1]

In a recent study, Servy et al. reported that 11.9% patients of their study population had skin manifestations, including purpura (8.0%), Osler nodes (2.7%), Janeway lesions (1.6%), and conjunctival hemorrhages (0.6%).[2] A few patients had more than one type of skin manifestations. They concluded that patients with skin manifestations had a higher rate of IE-related extracardiac complications than patients without skin manifestations, particularly cerebral emboli, without increased mortality. However, our patient did not have any such feature. It is also noteworthy that patients of IE with purpura had larger cardiac vegetations and Janeway lesions were associated with more extracerebral emboli.[2]

On the other hand, cutaneous infarctions are characterized by an area of focal necrosis as a result of vasculitis, thrombosis, or embolism due to various etiologies.[3]

They are painful, irregularly shaped, dark-colored lesions that can be depressed below the surface of the skin. We speculate that the cutaneous infarction in the present patient was due to emboli of vegetations. It is worth remembering that, cutaneous features may rarely be the presenting feature of IE. Conti and Barnet described a case of vasculitis leading to the diagnosis of IE.[4]

The unusual feature of the present patient was that he had no past history of any heart disease or cardiac symptom and presented with cutaneous infarcts as the presenting feature of IE. In about 40% of patients with IE caused by S. aureus, embolic complications may occur.[4] To conclude, the peripheral signs are immensely important in the diagnosis of IE. It is very important to consider IE when patients have fever, bacteremia, and evidence of embolic phenomena. This case report also emphasizes that cutaneous infarct may be a presenting feature of IE.

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