JANEWAY LESIONS - DIFFERENTIAL-DIAGNOSIS WITH OSLER NODES

A 25-year-old male drug abuser was admitted to the Emergency Unit of the General Hospital of Valencia in August 1992 with 40-degrees-C fever and chills for 2 days. He also complained about a left lumbar pain. The physical examination revealed only marked tenderness on deep pressure in the left costovertebral area. There was no cardiac murmur present, and no cutaneous lesions. In the emergency blood test, the white cell count was 24,400 x 10(9)/L (93% neutrophiles). The urine analysis showed pyuria and microhematuria. The chest x-ray was normal. He was admitted with the diagnosis of acute left pyelonephritis. Two days after admission, he continued to have high fever, and cutaneous lesions appeared. Small nontender erythematous spots were observed on the inner and the outer edges of both soles (Fig. 1). There were some lesions that became nodular and hemorrhagic on the right palm. At the same time we started to hear a systolic murmur at the apex. Two skin biopsies were taken: one was processed for light microscopy, and the other was cultured for bacteria. The first one was stained with hematoxylin and eosin and showed neutrophils in a microabscess in the papillar and reticular dermis, with a thrombus completely occluding some of the vessels (Fig. 2). The cultured biopsy was positive for Staphylococcus aureus. Other examinations included: positive blood cultures for Staphylococcus aureus, echocardiogram showed a large vegetation on the mitral valve, and the abdominal CT scan revealed splenomegaly and splenic infarcts. The treatment was started with intravenous cloxacillin (2g q hr) and gentamicin (80 mug q 8hr). The fever disappeared, and the skin lesions vanished after 3 weeks.