Janeway lesions: a valuable clinical sign in patients with infective endocarditis.

Embolic events are known clinical stigmata of infective endocarditis occurring in 20 to 50% of cases and are often associated with protracted bacteremia. Janeway lesions are an example of this embolic phenomenon and can be a silent clinical sign (1). In cases where patients are incapacitated to a point where history acquisition becomes challenging, identification of Janeway lesions can be an important dermatologic finding guiding further management. This can lead to performing an echocardiogram to look for valvular vegetations and early imaging of the brain for possible cerebral emboli (2).

Janeway lesions are usually flat, ecchymotic, and distal. They can be macular or nodular and can be clinically confused with Osler's nodes. The hallmark feature differentiating them from ‘Osler's nodes’ is that they tend to be non-tender and more commonly present on the palms and soles as compared to the fat pads of the fingers (Fig. 1). They are microabscesses with the source of infection being the endocardial vegetation; however, their pathological basis remains controversial. Osler's nodes on the contrary are an immunologic phenomena. Both these peripheral stigmata can aid tremendously in directing clinicians to order appropriate work up for early diagnosis of infective endocarditis (3).

Fig. 1

Janeway lesions (arrows) on the toes and sole, seen in a patient with massive aortic valve vegetation.