Janeway lesions, Osler nodes, Roth spots, splinter haemorrhages and clubbing
Mnemonic
FROM JANE:
- F - Fever
- R - Roth spots, retinal haemorrhages with pale centres
- O - Osler’s nodes, painful nodules on the finger pulps
- M - Murmur, new or changed
- J - Janeway lesions, painless palmar and plantar macules
- A - Anaemia
- N - Nail haemorrhages, splinters
- E - Emboli
“Osler’s are Ouchy, Janeway are painless” is the distinction most often asked: Osler’s nodes are immune complex mediated and tender; Janeway lesions are septic emboli and are not.
The modified Duke criteria formalise the diagnosis: 2 major, or 1 major plus 3 minor, or 5 minor. The major criteria are positive blood cultures with a typical organism and evidence of endocardial involvement on echocardiography.
Three sets of blood cultures from three sites before antibiotics, and a negative transthoracic echo does not exclude it, particularly with a prosthetic valve.
Expansion
| Sign | Nature | Mechanism |
|---|---|---|
| Osler nodes | Painful nodules on finger and toe pulps | Immune complex deposition |
| Janeway lesions | Painless macules on palms and soles | Septic emboli |
| Roth spots | Retinal haemorrhages with pale centres | Immune complex |
| Splinter haemorrhages | Linear subungual | Microemboli |
| Clubbing | Late sign | Chronic infection |
The Osler is Ouchy distinction is the reliable way to keep them apart, and the underlying mechanisms differ correspondingly: immune complex phenomena are painful and inflammatory, embolic phenomena are painless.
Other features: fever, new or changing murmur, splenomegaly, microscopic haematuria, and signs of embolic events including stroke and mycotic aneurysm.
Duke criteria combine major criteria (positive blood cultures with typical organisms, and echocardiographic evidence of vegetation or new regurgitation) with minor criteria (fever, predisposition, vascular and immunological phenomena, and equivocal microbiology).
Practical points: take three sets of blood cultures from separate sites before antibiotics, and remember that the classic peripheral signs are now uncommon, being seen mainly in subacute presentations, so their absence does not exclude the diagnosis.