A 4 years old, previously healthy girl presented with complaint of fever for 10 days. On examination, she was febrile with temperature of 102°F, heart rate of 115/min and respiratory rate of 23/min. There were multiple, nontender, erythematous macules present over the sole of the feet as shown in Figure 1. On cardiovascular examination, there was grade 3 systolic murmur over the apex. Abdominal examination was unremarkable. Investigations revealed total leukocyte count of 6800/mm3 (N = 76%, L = 21%), thrombocytopenia (platelet count: 75 000/mm3), elevated ESR of 55 mm/l and C-reactive protein positive. Blood culture grew methicillin sensitive staphylococcus aureus. Two-dimensional echo showed mitral regurgitation with vegetation in left atrium. In view of the above features, diagnosis of acute infective endocarditis with Janeway lesion was considered and she was started on cloxacillin and gentamicin. Fever and the lesions subsided by day 7 of antibiotics.
Photograph showing multiple erythematous, macules on sole of the feet.
Janeway lesions are one of the stigmata of infective endocarditis and are very rare in clinical practice.1 The lesions are irregular, erythematous, flat, painless macules on the palms and soles.2 They are usually seen with the acute form of bacterial endocarditis and typically last for days to weeks. The lesions are believed to be caused by septic microemboli from the valvular lesion and consist of microabscesses in the dermis with thrombosis of small vessels without vasculitis.3
Cutaneous microembolism may mimic Janeway lesion which may be seen in conditions like rheumatic heart disease, intracardiac thrombus, systemic lupus erythematosus, leukocytoclastic vasculitis, hemolytic anemia and gonococcemia. Skin biopsy may help in differentiating Janeway lesion from cutaneous microembolism in absence of typical clinical features of infective endocarditis.4
Conflict of interest: The authors declare there are no conflicts of interest and authors alone are responsible for the content and preparation of this manuscript.
