JANEWAY LESIONS - DIFFERENTIAL-DIAGNOSIS WITH OSLER NODES

A 25-year-old male drug abuser was admitted to the Emergency Unit of t he 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. T he physical examination revealed only marked tenderness on deep pressu re in the left costovertebral area. There was no cardiac murmur presen t, and no cutaneous lesions. In the emergency blood test, the white ce ll count was 24,400 x 10(9)/L (93% neutrophiles). The urine analysis s howed pyuria and microhematuria. The chest x-ray was normal. He was ad mitted with the diagnosis of acute left pyelonephritis. Two days after admission, he continued to have high fever, and cutaneous lesions app eared. Small nontender erythematous spots were observed on the inner a nd the outer edges of both soles (Fig. 1). There were some lesions tha t became nodular and hemorrhagic on the right palm. At the same time w e started to hear a systolic murmur at the apex. Two skin biopsies wer e taken: one was processed for light microscopy, and the other was cul tured for bacteria. The first one was stained with hematoxylin and eos in and showed neutrophils in a microabscess in the papillar and reticu lar dermis, with a thrombus completely occluding some of the vessels ( Fig. 2). The cultured biopsy was positive for Staphylococcus aureus. O ther 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.