What is the diagnosis and treatment for Janeway lesions?

Janeway Lesions: Diagnosis and Treatment

Janeway lesions are non-tender, erythematous macules or nodules found on the palms and soles that represent a vascular phenomenon and serve as a minor criterion for diagnosing infective endocarditis (IE). 1

Diagnosis

Clinical Characteristics of Janeway Lesions

• Non-tender, erythematous macules or nodules typically found on the palms and soles 2
• Distinguished from Osler nodes, which are painful and tender raised lesions typically found on the pads of fingers and toes 3, 2
• Represent vascular phenomena caused by septic emboli in the setting of IE 1
• Included as a minor criterion in the modified Duke criteria for diagnosing IE 1

When to Suspect Infective Endocarditis

• Presence of Janeway lesions should immediately trigger suspicion of IE, especially when accompanied by:
  • Fever lasting more than 48 hours 1
  • Cardiac murmur suggestive of valvular or congenital heart disease 1
  • Other physical findings such as petechiae, Osler's nodes, Roth spots, splenomegaly, or splinter hemorrhages 1
• Patients with predisposing factors are at higher risk:
  • Prosthetic heart valves 1
  • Congenital heart disease, especially complex cyanotic lesions 1
  • History of intravenous drug use 1, 4
  • Poor dentition or recent dental procedures 5

Diagnostic Workup

• Obtain at least 2-3 sets of blood cultures from different venipuncture sites before starting antibiotics 1
• Class I recommendation: Patients with unexplained fever for more than 48 hours who are at risk for IE should have at least 2 sets of blood cultures obtained from different sites 1
• Class III recommendation: Do not administer antibiotics before obtaining blood cultures in patients with known valve disease or valve prosthesis who present with unexplained fever 1
• Perform echocardiography:
  • Transthoracic echocardiography (TTE) as first-line imaging 1
  • Transesophageal echocardiography (TEE) if TTE is negative but clinical suspicion remains high 1
  • TEE is recommended in patients with prosthetic valves or complicated IE 1
• Apply modified Duke criteria for diagnosis of IE, where Janeway lesions contribute as a minor criterion under "vascular phenomena" 1

Treatment

Antimicrobial Therapy

• Once blood cultures are obtained, empiric antimicrobial therapy should be initiated if clinical suspicion is high 1
• Therapy should be tailored based on the identified pathogen:
  • Staphylococcus aureus is commonly associated with Janeway lesions 6, 7
  • Viridans streptococci are also common causative organisms 5
• Duration of therapy typically ranges from 4-6 weeks depending on the pathogen and presence of complications 1

Surgical Intervention

• Evaluation for surgical indications should include assessment for:
  • Heart failure due to valvular destruction 1
  • Uncontrolled infection 1
  • Prevention of embolic events 1
  • Large vegetation size 1
• Early surgical consultation is recommended for all complicated IE cases 1

Multidisciplinary Approach

• Management by an "Endocarditis Team" at a reference center is recommended for complicated cases 1
• The team should include:
  • Cardiologists for expertise in diagnosis, imaging, and clinical management 1
  • Infectious disease specialists for identification of causative organisms and antimicrobial therapy 1
  • Cardiac surgeons for decisions about timing and type of surgical intervention 1
  • Anesthesiologists for peri- and intraoperative management 1

Common Pitfalls to Avoid

• Delaying blood cultures or starting antibiotics before obtaining adequate cultures 1, 5
• Inadequate physical examination that misses characteristic skin findings 5
• Narrow focus thinking that overlooks the diagnosis of IE 5
• Not referring complicated cases to specialized centers with "Endocarditis Teams" 1
• Overlooking the need for surgical evaluation in complicated IE cases 1

Special Considerations

• Janeway lesions may be more commonly associated with acute rather than subacute endocarditis 2
• Histopathology of Janeway lesions shows evidence of suppuration and microabscesses in untreated cases 6
• In patients receiving appropriate therapy, Janeway lesions may show minimal inflammatory reaction 6