PMC7498957_01
Multiple nontender and noncompressible macular spots of varying sizes over both hand
(A) and foot (B) known as Janeway lesions (white arrows). Also a painful, red, raised
lesion found on the hand (A) known as Osler nodule (red arrow). (C) Splinter hemorrhage
underneath fingernail.
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Physical examination showed a thin, dry, lethargic female with Janeway lesions over palms and soles (white arrows, Figure 1A and B), Osler nodes (red arrow, Figure 1A), and splinter hemorrhages (Figure 1C).
(A) Angiogram of left anterior descending coronary artery showing 100% occlusion
without evidence of atherosclerotic coronary artery disease concerning for a septic
embolus (blue arrow). (B) Transesophageal echo view showing medium-sized, 1.3 cm (L) x
1.0 cm (W), mobile vegetation on the atrial aspect of the tip of the anterior leaflet of
mitral valve (red arrow). (C) Gross specimen showing vegetation involving the mitral
valve leaflets.
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TTE was requested and showed EF of 35% to 40% with severe diffuse hypokinesis of the apical wall and a possible vegetation on mitral valve. Transesophageal echocardiogram (TEE) was scheduled on day 4, confirming EF of 30% to 35% with severe hypokinesis and medium-sized, 1.3 cm (L) x 1.0 cm (W), mobile vegetation on the atrial aspect of the tip of the anterior leaflet of mitral valve associated with moderate to severe mitral valve regurgitation (red arrow, Figure 2B). An emergent cardiac catheterization revealed no signs of atherosclerotic coronary artery disease but a 100% occlusion of the proximal left anterior descending (LAD) artery suspicious for a septic embolus (blue arrow, Figure 2A). Gross specimen showed vegetations involving the mitral valve leaflets (Figure 2C).