Pre-antibiotic Era Manifestations of Infective Endocarditis in the Era of Modern Antimicrobials.

A 36-year-old man presented to the emergency department with a 3-week history of fever associated with chills and rigor, arthralgia, fatigue and weight loss. Physical examination revealed pallor, multiple, small erythematous, non-tender lesions on the soles (Fig. 1) and on the ventral surface of fingers suggestive of Janeway lesion (Fig. 2), infarction of right fifth toe (Fig. 1), and sub-conjunctival hemorrhage (Fig. 3). First and second heart sounds were normal and a murmur could not be appreciated. Blood cultures done at 0, 6 and 12 hours were negative for growth of any organism (patient had already received antibiotic at local center). Transthoracic echocardiography (TTE) revealed oscillating mass of size 6.7 mm × 5.6 mm hanging in aortic valve right coronary cusp however; there were no aortic stenosis or regurgitation (Video 1). These findings confirmed a diagnosis of native valve endocarditis. The non-suppurative peripheral manifestations of subacute endocarditis are result of prolonged infection; with early diagnosis and treatment, these have become infrequent [1]. Patient was managed with intravenous gentamicin 40 mg 8 hourly for 2 weeks and ceftriaxone 2 gram daily for 4 weeks. Following the treatment, the peripheral manifestations subsided (Fig. 4, Fig. 5, Fig. 6) and vegetation was not seen on repeat TTE done at 4 weeks and 8 weeks (Video 2).

Fig. 1

Janeway lesion on the soles and infarction of right fifth toe.

Fig. 2

Janeway lesion on fingers.

Fig. 3

Sub-conjunctival hemorrhage.

Fig. 4

Janeway lesion on the soles and infarction of right fifth toe subsided after treatment.

Fig. 5

Janeway lesion on fingers subsided after treatment.

Fig. 6

Sub-conjunctival hemorrhage subsided after treatment.

This is to conclude, head to toe examination is indispensable for all the patients presenting with fever, arthralgia, fatigue and weight loss.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Funding

None

Consent

Written informed consent for publication of clinical details, images and video was obtained from the patient.

Declaration of Competing Interest

The abstract was presented at fourth national conference of Society of Internal Medicine of Nepal (SIMON) at Birgunj, Nepal on 7th March, 2020.

Author’s contributions

Both the authors contributed equally.

Ethics approval and consent to participate

Not applicable.