July/August 2003

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Diagnosis: ORSA (oxacillin-resistant Staphylococcus aureus) endocarditis with septic emboli to skin.

Hospital Course:

The patient developed splinter hemorrhages, Roth spots, Janeway lesions, and Osler's nodes over the next few days (Figs 3, 4, and 5). The patient's pustules, blood, and CSF were sent for gram stain and culture. She was empirically started on vancomycin for extended gram-positive coverage. All body fluids sent grew oxacillin-resistant Staphylococcus aureus. Transthoracic echocardiography revealed severe mitral regurgitation. Transesophageal echocardiography revealed a large vegetation on the mitral valve. Imaging revealed septic emboli to brain, lungs, spleen, and bowel. The patient underwent mitral valve replacement and her status improved dramatically. She was discharged to home approximately 1.5 months after her admission.

Discussion:
Acute bacterial endocarditis is most commonly caused by Staphylococcus aureus. Staphylococcal bacteremia carries a 10% risk of endocarditis. Risk factors include dermatitis, intravenous drug injections, renal failure, organ transplantation, chronic hepatitis, poorly controlled diabetes mellitus, metastatic cancer, cardiovascular disease, postoperative wounds, or internal prosthetic devices. Most cases involve entry through a cutaneous route. Mortality ranges from 5-50% and is related to age, embolic events, and time of diagnosis.

Cutaneous manifestations include cutaneous purpura and petechiae, subungual splinter hemorrhages, Janeway lesions, Osler's nodes, and Roth's spots. Petechiae and hemorrhages are the most common mucocutaneous manifestation of bacterial endocarditis, present in 50% of patients. They frequently occur in small crops on the upper chest and extremities. They are thought to occur from small-vessel imflammation rather than embolic phenomena. Subungual splinter hemorrhages occur on the midportion of the nail bed and are suggestive, but not diagnostic, of bacterial endocarditis. Janeway lesions are painless erythematous macules to nodules on the palms or soles from septic emboli. Lesions with purulent purpura (white to gray centers with surrounding hemorrhagic halos) represent progression of Janeway lesions or initial metastatic pustules. Osler's nodes are small, erythematous, painful nodules on the pads of the fingers and toes, thenar and hypothenar eminences, and arms. They occur in crops and are transient, lasting 12-72 hours. Only 5% of patients with bacterial endocarditis develop these lesions. They arise from microemboli leading to vascular occlusion and localized vasculitis. Embolization to the eye results in sunconjunctival hemorrhage, cotton-wool exudates in the fundus, and Roth spots (oval shaped white areas in the retina surrounded by a zone of hemorrhage).

Immediate diagnosis and treatment of staphylococcal bacterial endocarditis is critical. Blood cultures and skin biopsy are helpful in diagnosis. Transesophageal echocardiogram is indicated to evaluate for endocarditis. The Duke criteria is often used to establish a definitive diagnosis of bacterial endocarditis. Treatment includes intravenous antibiotics (important to establish if oxacillin sensitive or resistant) and valve replacement, if indicated.

References:

1. Fitzpatrick's Dermatology in General Medicine, 5th ed. (Freedberg IM, Eisen AZ, Wolff K, Austen KF, Goldsmith LA, Katz SI eds.). New York: McGraw-Hill, 1999. pp 1940, 2191-2, 2201-2.

2. Andrew's Diseases of the Skin, 9th ed. (Odom RB, James WD, Berger TG, eds). Philadelphia: W.B. Saunders Co, 2000. p 307.

3. Mouly S et al. The changing clinical aspects of infective endocarditis: descriptive review of 90 episodes in a French teaching hospital and risk factors for death. J Infection 45:246-56, 2002.
My thanks to Drs.Helen Kim-James and Dustin James for their assistance in tne preparation of this case.