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Original Investigation |

Prognostic Value of Skin Manifestations of Infective Endocarditis ONLINE FIRST

Amandine Servy, MD1; Laurence Valeyrie-Allanore, MD1; François Alla, MD, PhD2; Catherine Lechiche, MD3; Pierre Nazeyrollas, MD, PhD4; Christian Chidiac, MD, PhD5; Bruno Hoen, MD, PhD6; Olivier Chosidow, MD, PhD1,7; Xavier Duval, MD, PhD8; for the Association Pour l’Etude et la Prévention de l’Endocardite Infectieuse Study Group
[+] Author Affiliations
1Department of Dermatology, Centre Hospitalier Universitaire (CHU) Henri-Mondor Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP), Créteil, France
2Centre d’Investigation Clinique–Epidémiologie Clinique, CHU de Nancy, Nancy, France
3Department of Infectious and Tropical Diseases, CHU de Caremeau, Nîmes, France
4Departments of Cardiology and Therapeutics, CHU de Reims, Faculté de Médecine, Reims, France
5Department of Infectious and Tropical Diseases, CHU Hôpital de la Croix Rousse, Lyon, France
6Department of Infectious and Tropical Diseases, CHU de Besançon, Unité Mixte de Recherche Centre Nationale de Recherche Scientifique 6249 Chrono-Environnement, Université de Franche-Comté, Besançon, France
7Université Paris–Est Créteil Val-de-Marne, Institut National de la Santé et de la Récherche Médicale (INSERM), Centre d’Investigation Clinique (CIC) 006, Créteil, France
8INSERM CIC 007, AP-HP, CHU Bichat, INSERM Unité 738, Université Paris Diderot, Unité de Formation et de Recherche de Médecine, Site Bichat, Paris, France
JAMA Dermatol. Published online February 05, 2014. doi:10.1001/jamadermatol.2013.8727
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Importance  Infective endocarditis (IE) is a rare disease with poor prognosis. When IE is suspected, skin examination is mandatory to look for a portal of entry and classic skin lesions to help diagnose and manage the condition.

Objectives  To describe the prevalence of and factors associated with dermatological manifestations in patients with definite IE.

Design  Observational, prospective, population-based epidemiological study between January 1 and December 31, 2008. Subsequently, collected dermatological data were subjected to post hoc analysis.

Setting and Participants  Patients (n = 497) diagnosed in 7 French regions and hospitalized in France for definite IE satisfying modified Duke criteria.

Main Outcomes and Measures  Patient and disease epidemiological information was collected, focusing on the most classic dermatological manifestations of IE (Osler nodes, Janeway lesions, purpura, and conjunctival hemorrhages). Disease outcome was also recorded.

Results  Among 497 definite IE cases, 487 had known dermatological status. Of 487 cases, 58 (11.9%) had skin manifestations, including 39 (8.0%) with purpura, 13 (2.7%) with Osler nodes, 8 (1.6%) with Janeway lesions, and 3 (0.6%) with conjunctival hemorrhages (5 patients had 2 skin manifestations). Patients with skin manifestations had a higher rate of IE-related extracardiac complications than patients without skin manifestations, particularly cerebral emboli (32.8% vs 18.4%, P = .01), without increased mortality. Patients with purpura had larger cardiac vegetations (18.1 vs 13.7 mm, P = .01), and Janeway lesions were associated with more extracerebral emboli (75.0% vs 31.8%, P = .02).

Conclusions and Relevance  Specific skin manifestations of IE are associated with a higher risk of complications and should alert physicians to examine for extracardiac complications, notably with cerebral imaging.

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Figure.
Classic Lesions Associated With Infective Endocarditis

A, Osler nodes on the right thumb characterized by a painful distal erythematous and hemorrhagic bullous lesion. B, Extensive distal infiltrated purpura evolving to necrosis of the legs. C, Erythematous purpuric macules of the sole corresponding to a Janeway lesion. From the collection of the Department of Dermatology, Centre Hospitalier Universitaire Henri-Mondor Hospital, Assistance Publique–Hôpitaux de Paris, Créteil, France.

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Osler nodes and Janeway lesions do have various clinical presentations and characteristics
Posted on February 27, 2014
Benjamin Davido 1, Nicolas Davido 2, Pierre de Truchis 1, Anne-Claude Cremieux 1
1 Infectious Diseases Department, Raymond Poincaré Teaching Hospital Garches France, 2 Odontology Department, Pitié Salpétrière Paris France
Conflict of Interest: None Declared

The study by Servy et al. (Feb. issue) states that a complete dermatological examination is essential for the management of infectious endocarditis (IE). We know that the classic dermatological lesions, described in the paper which are suggestive of septicemia may lead physicians to evoke an IE according to the Duke’s criteria. Servy et al. explain that these cutaneous manifestations are also signs of infection severity associated with a higher risk of cerebral complications that should alert physicians. Servy et al. remind us that Osler nodes are purple painful nodes, mainly localized on fingertips, pulp of the toes, palms, soles, or sometimes on the ears. However, physician can be faced to additional locations of these nodes such as the forearms [1], and other rarer locations such as the flank and the trunk [2] or even on the thigh [3]. We remind the readers that the legendary cutaneous lesions may also appear with slightly different characteristics including different size and shape compared to the first clinical descriptions [1]. Therefore, distinguishing Osler nodes from Janeway lesions may be difficult [4], but the main goal is to identify such skin manifestations of IE. Servy et al. report 11.9% of skin manifestations in his issue. The prevalence rates may surely be underestimated in the absence of systematic dermatological examination. Nowadays, physicians disregard clinical exam for the benefit of complementary investigations which are inescapable once we have evocated the diagnosis of IE, but these investigations don’t exempt them from dermatological examination. We do believe that the best strategy to identify rapidly such lesions must involve all physicians. Servy’s proposal to prefer an experienced physician or a dermatologist to examine the patient, may contribute to underestimate these fleeting and rare lesions which are so important to identify. References: [1] Osler W. Chronic infectious endocarditis. Q J Med 1909; 2:219-30[2] Urbano FL. Peripheral signs of endocarditis. Hosp Physician 2000; 36:41-46. [3] Davido B, Davido N, Cremieux AC, de Truchis P, Perronne C. Osler's node on the thigh, an uncommon location, but a valuable diagnostic aid, Intern Emerg Med. 2014 Feb 26. [Epub ahead of print] [4] Marrie TJ. Osler's nodes and Janeway lesions. Am J Med 2008; 121 (2):105-6

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