Case Presentation:
The patient is a 43 year old female with a past medical history significant for IVDA, alcoholism, and recent cocaine use who presented to the emergency department with severe agitation and complaints of diffuse pain. The patient was found to have 3/4 SIRS criteria, though no identifiable source of infection was found. As there was concern for sepsis, the patient was started on empiric antibiotic treatment with IV Vancomycin and Cefepime. She was admitted to the MICU, where she required intubation due to respiratory failure. After stabilization in the MICU for 24 hours, the patient was successfully extubated and was transferred to the floor for further care.
While on the floor, the patient developed a non‐specific rash on the 2nd, 4th and 5thPIP joints of her right hand. The rash consisted of erythematous, raised, tender lesions, representing Osler’s nodes. The patient also had scattered non‐tender, hemorrhagic, macules on the palmar aspect of her finger‐tips, consistent with Janeway lesions.
Discussion:
Given these cutaneous findings, the concern for endocarditis was high. Work‐up for endocarditis including blood cultures, an echocardiogram and a TEE were all found to be negative. HIV testing was done and was also negative. Dermatology was consulted for evaluation of these lesions as the previously mentioned studies for endocarditis were negative. As the dermatology team also believed the lesions to be Osler’s nodes, a skin biopsy was obtained. The results identified epidermal acanthosis and scale crust with brisk superficial and deep perivascular inflammation. The infiltrate was comprised of lymphocytes, neutrophils and rare eosinophils. Neither vasculitis nor vascular thrombosis was identified in the biopsy. With the etiology of these lesions still unknown, additional workup was done. This included ruling out occult malignancy via tumor markers (CEA, CA‐125, CA‐15‐3, and CA 19‐9), SLE (ANA), Coxsackie virus, disseminated gonorrhea and autoimmune processes (anti‐SS A, anti‐SS B, ANCA), all of which were found to be negative. A CT chest/abdomen/pelvis was also obtained, though only revealed a small pulmonary nodule.
Conclusions:
This case is unique in that it describes the finding of Osler’s nodes with an idiopathic etiology. A full work‐up to rule out all known causes of Osler’s nodes, including infective endocarditis, Marantic endocarditis, SLE, disseminated gonococcal infection, occult malignancy, and autoimmune processes, were all found to be negative.