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Volume 5, Issue 4 (October-December, 2015)

Janeway Lesions and Cerebral Hemorrhage in Staphylococcal Endocarditis

download_pdf1Authors: Zain Ul Abideen [1],Nabeel Akram [1], AbairUlHaq [1]

Affiliation: [1] Department of Internal Medicine, Shifa International Hospital, Islamabad, Pakistan

Conflict of Interest: None declared

This article has been peer reviewed.

Article Submitted on: 1st January 2015

Article Accepted on: 18th April 2015

Funding Sources: None declared

Correspondence to:Dr Zain UlAbideen

Address: Department of Medicine, Shifa International Hospital, Islamabad, Pakistan

E-mail: [email protected]

Cite this Article: Abideen ZU, Akram N, Haq AU. Janewaylesions and cerebral hemorrhage in staphylococcal endocarditis. J Pioneer Med Sci 2015; 5(4):140-141

JPMS-VOL5-ISSUE4-PAGES140-141-IMAGE1Clinical Images

A 65-year-old male with end stage renal disease requiring hemodialysis, presented with high grade fever accompanied by rigors and chills, lethargy and joint aches for five days. His white cell count was 18700/µL (normal range 4000-11000/µL) and C-reactive protein level was 475 mg/L (normal range up to 5 mg/L). On the second day of his admission, he developed sudden loss of vision in his left eye and blurring of vision in the right. Blood cultures grew Methicillin-resistant Staphylococcus aureus (MRSA). A computed tomography (CT) scan of the head revealed small hematomas in the right occipital and left temporal lobes of the brain and magnetic resonance imaging (MRI) confirmed findings of a hemorrhagic infarct in the right occipital lobe (Figure 1).

Ophthalmoscopy and B scan ultrasound of the left eye found absent red reflex and vitreous hemorrhage. The same day, he developed reddish/purple, macular and non-tender lesions on his palms and left foot as shown in Figure 2. Patient fulfilled Duke’s criteria for endocarditis and was started on vancomycin and rifampicin. JPMS-VOL5-ISSUE4-PAGES140-141-IMAGE2Trans-esophageal echo revealed small vegetations on the mitral and tricuspid valves. There was remarkable improvement in the constitutional symptoms and inflammatory markers. Vision in the left eye improved partially with bevacizumab.

First reported by Edward G Janeway in 1898, Janeway lesions are a classic but uncommon manifestation of infective endocarditis [1]. These lesions signify septic embolization, are macular, non-tender and found on the palms and soles. These lesions are most commonly associated with acute endocarditis secondary to Staphylococcus aureus.  Histologically, lesions consist of small abscesses in the dermis with thrombosis of small vessels [2].These lesions are uncommonly seen in current clinical practice due to early and rigorous management of infective endocarditis but were more commonly observed in the pre-antibiotic era.

JPMS-VOL5-ISSUE4-PAGES140-141-IMAGE3 Cerebral hemorrhage accounts for 12 to 30% of all neurological complications of infective endocarditis [3]. This complication is much more common with Staphyloccocalbacteremia, thrombocytopenia and anticoagulant use [4]. Mechanisms postulated for cerebral hemorrhages include transformation of ischemic infarcts by septic emboli, rupture of intracranial mycoticaneurysms and septic erosion of the arterial walls without a well-defined aneurysm.Cerebral hemorrhage secondary to MRSA endocarditis is most commonly associated with the last mechanism [5].

REFERENCES

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  2. Tan JS, Kerr A Jr. Biopsies of the Janeway lesion of infective endocarditis.J CutanPathol 1979;6:124–9.
  3. Sonneville R, Mirabel M, Hagège D, Tubach F, Vignon P, Perez P, et al. Neurologic complications and outcomes of infective endocarditis in critically-ill patients: the ENDOcarditeenREAnimation prospective multicenter study. Crit Care Med 2011; 39:1474-81.
  4. Mourvillier B, Trouillet JL, Timsit JF, Baudot J, Chastre J, Régnier B, et al. Infective endocarditis in the intensive care unit: clinical spectrum and prognostic factors in 228 consecutive patients. Intensive Care Med 2004; 30:2046-52.
  5. Sonneville R, Mourvillier B, Bouadma L, Wolff M. Management of neurological complications of infective endocarditis in ICU patients. Ann Intensive Care 2011; 1:10.