SAEM Clinical Images Series: Painful Great Toe

Yes, the patient should be admitted; an Osler node or Janeway lesion is indicative of active endocarditis. An Osler node is a painful, tender, nodular lesion that is bluish-purple and is located on the distal phalanx of the fingers or toes. Classically, pain precedes any swelling, with subsequent discoloration occurring with skin pigmentation being described as reddish, cyanotic, bluish-purple, vivid pink, or erythematous. The skin may desquamate or darken, but ulceration is rare. Histologic evaluation reveals necrotizing vasculitis and inflammatory infiltration of the vascular channels. Aspiration and culture of the lesions typically yields no organisms, though several case reports note positive bacterial growth with organisms that match the underlying endocarditis bacteria. Whether an Osler node is caused by micro-septic emboli or by an immune response is a controversy that has not yet been settled. Janeway lesions, also seen in endocarditis, are similar discolored macules on the palms or soles. However, Janeway lesions are normally painless, which is a key factor that differentiates them from Osler nodes. Osler nodes or Janeway lesions are indicative of active endocarditis. Patients with these lesions, such as the patient in this case, should be admitted for blood cultures, echocardiography, and intravenous antibiotics. This patient was admitted, and his echo confirmed multiple vegetative lesions with severe aortic valvular disease. The patient was subsequently transferred for valve replacement surgery after three weeks of intravenous antibiotics.