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Difficulty: MediumPhysical Examination Findings

A 45-year-old man is evaluated in the emergency department for a 3-week history of low-grade fever, chills, night sweats, and generalized myalgias. He has a known history of a bicuspid aortic valve but has not followed up with a cardiologist in several years. His temperature is 38.4°C (101.1°F), blood pressure is 142/50 mmHg, and heart rate is 98/min. Cardiac auscultation reveals a high-pitched, decrescendo diastolic murmur loudest at the right upper sternal border. The physician highly suspects an infectious process involving the endocardium. Which of the following physical examination findings are classically associated with the suspected diagnosis? (Select all that apply)

  1. Non-tender, erythematous, macular lesions on the palms and solesAnswer
  2. Tender, violaceous subcutaneous nodules on the distal pads of the digitsAnswer
  3. Dark red, linear lesions in the nail beds that do not blanch with pressureAnswer
  4. D
    Erythematous, serpiginous macular lesions with pale centers on the trunk
  5. E
    Firm, painless subcutaneous nodules over the extensor surfaces of the elbows

Answer

The correct findings are non-tender, erythematous, macular lesions on the palms and soles (Janeway lesions); tender, violaceous subcutaneous nodules on the distal pads of the digits (Osler nodes); and dark red, linear lesions in the nail beds that do not blanch with pressure (splinter hemorrhages).
The patient's presentation of a prolonged fever, a predisposing structural heart defect (bicuspid aortic valve), and a new decrescendo diastolic murmur with a wide pulse pressure is highly indicative of infective endocarditis (IE) complicated by acute aortic regurgitation. The peripheral physical examination stigmata that strongly support a diagnosis of IE include Janeway lesions (non-tender, erythematous macules on the palms and soles caused by septic microemboli), Osler nodes (tender, violaceous nodules on the digit pads caused by immune complex deposition), and splinter hemorrhages (dark red, linear nail bed lesions resulting from capillary vasculitis).

Step-by-Step Solution

1
Analyze the clinical vignette to identify the primary suspected diagnosis.
The patient has a persistent fever, a known predisposing cardiac anomaly (bicuspid aortic valve), and signs of new aortic regurgitation (wide pulse pressure and a decrescendo diastolic murmur).
Recognizing this constellation of symptoms correctly identifies infective endocarditis as the primary diagnosis.
2
Recall the classic peripheral physical examination stigmata associated with the suspected diagnosis.
Infective endocarditis is classically associated with Janeway lesions, Osler nodes, splinter hemorrhages, and Roth spots.
These findings are critical diagnostic clues that result from septic microembolization or immune complex deposition.
3
Evaluate the answer choices to select the accurate physical examination findings.
The options describing Janeway lesions, Osler nodes, and splinter hemorrhages accurately reflect infective endocarditis. The remaining options describe findings of acute rheumatic fever.
Differentiating between the dermatologic manifestations of infective endocarditis and other febrile illnesses with murmurs ensures accurate clinical diagnosis.

Key Concept

Peripheral Physical Stigmata of Infective Endocarditis
Estimated Time:1m 30s
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Topics

Physical Examination Findings

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