a 50-year - old female patient with visual disturbance was referred to chungnam national university hospital by an ophthalmologist for further evaluation of a cardiac murmur . the patient had experienced blurred vision and pain in both eyes for 5 days , and had a history of pain in the lower legs that had lasted for 3 months , coinciding with a persistent mild fever . a skin rash with tenderness was present on the palms and the soles of the feet and had lasted for 2 months . the patient had previously received 2 weeks of acupuncture treatments of the neck and back at an oriental medical clinic in an attempt to reduce pain . in addition , the patient had been taking non - steroidal anti - inflammatory drugs for 2 months as prescribed by a local clinic , but the mild fever persisted and did not improve . the patient had a chronically ill , anemic appearance , and presented with a mild fever ( 37.8c ) , tachypnea , and a blood pressure of 110/80 mmhg . an ophthalmic examination revealed reduced visual acuity in both eyes ; fundoscopy showed bilateral roth spots and optic disc edema with retinal hemorrhages ( fig . chest auscultation revealed a diastolic decrescendo murmur at the right and left upper sternal border . the laboratory examination showed marked leukocytosis ( 21,000/mm , 88% neutrophils , and 7% lymphocytes ) and a c - reactive protein level of 13 mg / l . an electrocardiogram showed a normal sinus rhythm and a chest x - ray showed bilateral pleural effusions . brain magnetic resonance imaging revealed a sub - arachnoid hemorrhage in the frontal and right occipital lobes , as well as multifocal microhemorrhages in the bilateral cerebellum and the left occipital , left parietal , and left frontal lobes . transthoracic and transesophageal echocardiograms showed combined severe aortic regurgitation and 821-mm and 620-mm echogenic masses with high mobility attached to the left ventricular sides of the right and left coronary cusps , respectively . a peripheral blood culture showed on the fourth day in the hospital , the patient underwent aortic valve replacement . after transverse aortotomy , we found huge vegetations on 3 aortic cusps and a small aortic wall abscess in the aortic wall above the noncoronary cusp . the aortic valve was severely damaged , so we performed aortic valve replacement with a mechanical prosthetic valve . postoperative care and follow - up examinations were performed , including a weekly blood culture , echocardiogram , fundoscopic exams , and 6 weeks of intravenous antibiotics . the pain in the patient s palms , soles , and lower limbs resolved on postoperative day ( pod ) 4 , and the skin lesions resolved after 2 weeks . the visual complications started to improve on pod 2 and had completely resolved on pod 7 . a fundoscopic examination showed that the hemorrhages with roth spots remained present for 4 weeks postoperatively , but were nearly absorbed by the 6th week postoperatively . the patient was discharged after 6 weeks of intravenous antibiotics and routine follow - up at our outpatient division . after transverse aortotomy , we found huge vegetations on 3 aortic cusps and a small aortic wall abscess in the aortic wall above the noncoronary cusp . the aortic valve was severely damaged , so we performed aortic valve replacement with a mechanical prosthetic valve . postoperative care and follow - up examinations were performed , including a weekly blood culture , echocardiogram , fundoscopic exams , and 6 weeks of intravenous antibiotics . the pain in the patient s palms , soles , and lower limbs resolved on postoperative day ( pod ) 4 , and the skin lesions resolved after 2 weeks . the visual complications started to improve on pod 2 and had completely resolved on pod 7 . a fundoscopic examination showed that the hemorrhages with roth spots remained present for 4 weeks postoperatively , but were nearly absorbed by the 6th week postoperatively . the patient was discharged after 6 weeks of intravenous antibiotics and routine follow - up at our outpatient division . infective endocarditis is characterized by inflammation of the endothelium of the heart ; it most commonly affects heart valves . symptoms are usually nonspecific and include fever , chills , anorexia , myalgia , and dyspnea . the clinical signs of endocarditis are numerous and nonspecific ; heart murmur is the most common sign . the peripheral signs can be useful in diagnosis but are less commonly used because of advancements in diagnostic modalities . there are four peripheral signs of endocarditis : roth spots , osler nodes , janeway lesions , and splinter hemorrhages . the white center of a roth spot is thought to be a leucocyte accumulation or platelet - fibrin plug . although roth spots are a classic peripheral sign of endocarditis , they are also present in other conditions , including hematologic malignancies , connective tissue diseases , vasculitis , anemia , hypertension , diabetes mellitus , human immunodeficiency virus infections , and intracranial hemorrhages . however , previous reports have stated that early interventions with medical or surgical modalities achieved good results . the pathogenesis of osler nodes is unclear , but is thought to involve the deposition of immune complexes . however , osler nodes are also found in other conditions , including bacteremia , septic endarteritis , typhoid fever , disseminated gonococcal infection , and systemic lupus erythematosus . the usual sites of osler nodes are the pads of the fingers and toes , but occasionally they appear on the mucous membranes , limbs , and trunk . with adequate intravenous antibiotics , osler nodes resolve without any sequelae within 3 days . in this case , we found painful nodular lesions on the patient s palms and soles , which were relieved 4 days postoperatively . janeway lesions are non - tender , small , erythematous , or hemorrhagic macular lesions . first , they are not tender ; second , they are not of immunological origin ; and lastly , they present on the palms and soles rather than on the pads of the fingers and toes . we found janeway lesions on the patient s palms and soles , and they resolved within 4 days after surgery . they are a non - specific sign of endocarditis and are also seen in scleroderma , trichinosis , systemic lupus erythematosus , rheumatoid arthritis , psoriasis , antiphospholipid syndrome , hematological malignancy , and trauma . sandre and shafran   reported the incidence of peripheral signs of endocarditis as follows : 3% for roth spots , 6.7% for osler nodes , 2.2% for janeway lesions , and 39% for splinter hemorrhages , but no report has previously described a patient with all 4 peripheral signs . we report here a case of subacute infective endocarditis with all 4 classic peripheral signs .
a 50-year - old female patient with visual disturbances was referred for further evaluation of a heart murmur . 
 fundoscopy revealed a roth spot in both eyes . 
 a physical examination showed peripheral signs of infective endocarditis , including osler nodes , janeway lesions , and splinter hemorrhages . 
 our preoperative diagnosis was subacute bacterial endocarditis with severe aortic regurgitation . 
 the patient underwent aortic valve replacement and was treated with intravenous antibiotics for 6 weeks postoperatively . 
 the patient made a remarkable recovery and was discharged without complications . 
 we report this case of subacute endocarditis with all 4 classic peripheral signs in a patient who presented with visual disturbance .