What are the classic physical exam findings associated with infective endocarditis (IE)?

Classic Physical Exam Findings in Infective Endocarditis

The correct answer is C: Janeway lesions, Osler nodes, Roth spots, and splinter hemorrhages represent the classic peripheral stigmata of infective endocarditis recognized in the modified Duke criteria. 1

Understanding the Duke Criteria Framework

The diagnosis of IE is based on the modified Duke criteria, which categorize findings into major and minor criteria. 1 The physical exam findings in question fall under minor criteria and are specifically classified as either:

• Vascular phenomena: Janeway lesions, splinter hemorrhages, major arterial emboli, septic pulmonary infarcts, mycotic aneurysms, intracranial hemorrhage, and conjunctival hemorrhages 1
• Immunological phenomena: Osler nodes, Roth spots, glomerulonephritis, and rheumatoid factor 1

Why Each Answer Choice Is Right or Wrong

Option A - Incorrect

• Fever is indeed a minor criterion 1, but history of IE is NOT a diagnostic finding—it's a predisposing condition or risk factor 1
• Roth spots and Osler nodes are correct findings 1
• This option conflates risk factors with diagnostic findings

Option B - Incorrect

• Fever >38°C is a minor criterion 1
• Janeway lesions and Osler nodes are correct 1
• Track marks on arms indicate injection drug use, which is a predisposing condition (minor criterion as "predisposition"), not a classic physical finding of IE itself 1
• While IV drug use increases IE risk, track marks are not peripheral stigmata of the disease 2, 3

Option C - CORRECT

• Janeway lesions (vascular phenomenon) 1
• Osler nodes (immunological phenomenon) 1
• Roth spots (immunological phenomenon) 1
• Splinter hemorrhages (vascular phenomenon) 1
• All four are recognized peripheral stigmata in the modified Duke criteria 1

Option D - Incorrect

• Chills and fatigue are nonspecific constitutional symptoms, not classic physical exam findings 1
• Splinter hemorrhages and Osler nodes are correct 1
• This option includes symptoms rather than objective physical exam signs

Clinical Context and Modern Presentation

Important caveat: While these classic findings are codified in the Duke criteria, peripheral stigmata are increasingly uncommon in developed countries as patients present earlier in the disease course. 1 However, vascular and immunological phenomena such as splinter hemorrhages, Roth spots, and embolic events still occur in approximately 30% of patients. 1

The American College of Cardiology and American Heart Association emphasize that Janeway lesions should immediately trigger suspicion of IE, especially when accompanied by fever lasting more than 48 hours and cardiac murmur. 2 The presence of these skin manifestations may be associated with higher complication rates and worse prognosis. 4

Practical Recognition

• Janeway lesions: Painless, hemorrhagic macules on palms/soles (vascular/embolic) 1, 2
• Osler nodes: Painful, tender nodules on finger/toe pads (immunological) 1, 5
• Roth spots: Retinal hemorrhages with pale centers (immunological) 1
• Splinter hemorrhages: Linear hemorrhages under nails (vascular/embolic) 1, 3

These findings, when present alongside fever and other clinical features, should prompt immediate blood cultures (at least 2-3 sets from different sites) and echocardiography. 2, 5