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Prognostic Value of Skin Manifestations of Infective Endocarditis

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Prognostic Value of Skin Manifestations of Infective Endocarditis Research Original Investigation Prognostic Value of Skin Manifestations of Infective Endocarditis Amandine Servy, MD; Laurence Valeyrie-Allanore, MD; François Alla, MD, PhD; Catherine Lechiche, MD; Pierre Nazeyrollas, MD, PhD; Christian Chidiac, MD, PhD; Bruno Hoen, MD, PhD; Olivier Chosidow, MD, PhD; Xavier Duval, MD, PhD; for the Association Pour l’Etude et la Prévention de l’Endocardite Infectieuse Study Group Supplemental content at IMPORTANCE Infective endocarditis (IE) is a rare disease with poor prognosis. When IE is jamadermatology.com suspected, skin examination is mandatory to look for a portal of entry and classic skin lesions to help diagnose and manage the condition. OBJECTIVES To describe the prevalence of and factors associated with dermatological manifestations in patients with definite IE. DESIGN Observational, prospective, population-based epidemiological study between January 1 and December 31, 2008. Subsequently, collected dermatological data were subjected to post hoc analysis. SETTING AND PARTICIPANTS Patients (n = 497) diagnosed in 7 French regions and hospitalized in France for definite IE satisfying modified Duke criteria. MAIN OUTCOMES AND MEASURES Patient and disease epidemiological information was collected, focusing on the most classic dermatological manifestations of IE (Osler nodes, Janeway lesions, purpura, and conjunctival hemorrhages). Disease outcome was also recorded. RESULTS Among 497 definite IE cases, 487 had known dermatological status. Of 487 cases, 58 (11.9%) had skin manifestations, including 39 (8.0%) with purpura, 13 (2.7%) with Osler nodes, 8 (1.6%) with Janeway lesions, and 3 (0.6%) with conjunctival hemorrhages (5 patients had 2 skin manifestations). Patients with skin manifestations had a higher rate of IE-related extracardiac complications than patients without skin manifestations, particularly cerebral emboli (32.8% vs 18.4%, P = .01), without increased mortality. Patients with purpura had larger cardiac vegetations (18.1 vs 13.7 mm, P = .01), and Janeway lesions were associated with more extracerebral emboli (75.0% vs 31.8%, P = .02). CONCLUSIONS AND RELEVANCE Specific skin manifestations of IE are associated with a higher risk of complications and should alert physicians to examine for extracardiac complications, notably with cerebral imaging. Author Affiliations: Author affiliations are listed at the end of this article. Group Information: The Association Pour l’Etude et la Prévention de l’Endocardite Infectieuse Study Group investigators are listed at the end of this article. Corresponding Author: Amandine Servy, MD, Department of Dermatology, Centre Hospitalier Universitaire Henri-Mondor Hospital, Assistance Publique–Hôpitaux de Paris, 51 Avenue du Maréchal-de-Lattre-de-Tassigny, JAMA Dermatol. 2014;150(5):494-500. doi:10.1001/jamadermatol.2013.8727 94010 Créteil CEDEX, France Published online February 5, 2014. ([email protected]). 494 jamadermatology.com Copyright 2014 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Skin Manifestations of Infective Endocarditis Original Investigation Research nfective endocarditis (IE) affects 2 to 6 individuals per which remains unclear. Therefore, using data from a large French 100 000 person-years in industrialized countries. Inpa- general population–based epidemiological study, we analyzed I tient mortality approaches 20%, particularly due to septic the prevalence of the 4 main dermatological manifestations of shock, heart failure, or stroke.1 The epidemiological profile of IE (Osler nodes, Janeway lesions, purpura, and conjunctival IE has evolved progressively, with increasing percentages of hemorrhages) and their possible associated factors. health care–associated IE, Staphylococcus aureus involve- ment, and prosthetic and degenerative native valve IE.2-4 A complete dermatological physical examination is essen- Methods tial for the management of IE. Indeed, a cutaneous portal of entry is found for more than 20% of the cases,5 and dermato- Study Design logical lesions suggestive of septicemia (Osler nodes, Janeway The study was approved by an institutional review board lesions, purpura, and splinter and conjunctival hemor- (Comité de Protection des Personnes, Besançon, France, De- rhages) may help physicians reach a clinical diagnosis. Nev- cember 2007). In accord with French law at that time, pa- ertheless, it can be difficult to discriminate among these clas- tients were informed of the study orally but did not have to sic dermatological lesions (Figure) and nonspecific provide written individual consent. descriptions. Distinguishing between Janeway lesions and Os- Between January 1 and December 31, 2008, the Associa- ler nodes is not that obvious.6 Osler nodes are described as tion Pour l’Etude et la Prévention de l’Endocardite Infec- purple painful nodes, mainly localized on fingertips, pulp of tieuse Study Group17,18 conducted an exhaustive observa- the toes, palms, soles, or sometimes on the ears.6 Lesions dis- tional and prospective analysis of all IE cases occurring in 7 appear within a few days without sequelae, occasionally in a French regions (Franche-Comté, Ille-et-Vilaine, Languedoc- few hours. Janeway lesions are often small, nontender, ery- Roussillon, Lorraine, Marne, Île-de-France, and Rhône-Alpes).17 thematous, and painless macules or papules on the palms or The 15 million inhabitants of these regions account for 32% of soles, sometimes purpuric or hemorrhagic.5,7 They tend to last the French population (http://www.insee.fr/fr/themes days to weeks before healing completely. Histological find- /document.asp?ref_id=ip1220). Only definite IE cases satisfy- ings for both lesions, described in case reports,8-15 include sep- ing Duke criteria revised by Li et al19 (eTable in the Supple- tic emboli with inflammatory reactions, and culture of le- ment) among patients 18 years or older and living in one of the sions can grow pathologic microorganisms. Vascular purpura, study regions were considered for this analysis. usually necrotic, is more frequent and typical. Purpura is most All hospital physicians usually managing IE (ie, cardiolo- often localized on lower parts of the body (legs and back) and gists [P.N. and X.D.], cardiac surgeons, infectious disease spe- sometimes on mucosa (conjunctivae and mouth) or near the cialists [C.L., C.C., and B.H.], intensivists, and internists) were clavicles. The findings on histological examination of pur- aware of this epidemiological study and notified all their pa- pura have been shown to be primarily septic emboli or leuko- tients. Then, Association Pour l’Etude et la Prévention de cytoclastic vasculitis.16 Splinter (longitudinal striations along l’Endocardite Infectieuse investigators transferred collected data the major nail axis) and conjunctival hemorrhages are also ob- from medical records to standardized case report forms. The fol- served in IE but are not pathognomonic of it. lowing information was collected for each patient: sex, age, Despite the importance of the skin for positive and etio- medical history, procedures and at-risk factors for IE, clinical logical IE diagnosis, few nondermatological investigations have signs and symptoms, portal of entry, laboratory and microbi- analyzed the manifestations of cutaneous IE, the prevalence of ology test results, imaging findings, medical and surgical treat- Figure. Classic Lesions Associated With Infective Endocarditis A B C A, Osler nodes on the right thumb characterized by a painful distal the sole corresponding to a Janeway lesion. From the collection of the erythematous and hemorrhagic bullous lesion. B, Extensive distal infiltrated Department of Dermatology, Centre Hospitalier Universitaire Henri-Mondor purpura evolving to necrosis of the legs. C, Erythematous purpuric macules of Hospital, Assistance Publique–Hôpitaux de Paris, Créteil, France. jamadermatology.com JAMA Dermatology May 2014 Volume 150, Number 5 495 Copyright 2014 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/29/2021 Research Original Investigation Skin Manifestations of Infective Endocarditis ment, and complications. A dermatological examination was not though transthoracic echocardiography diagnosed IE in al- systematically performed. Among clinical data, the following most half of the patients, transesophageal echocardiography 4 classic dermatological manifestations of IE were diagnosed was almost always performed to confirm the diagnosis and to according to each physician’s personal experience with IE and identify heart complications. recorded: Osler nodes, Janeway lesions, purpura, and conjunc- Time to IE diagnosis was similar regardless of dermato- tival hemorrhages. All case report forms were checked by an ad- logical manifestation status (P = .90), usually less than 1 month. judication committee composed of an infectious disease spe- However, compared with patients having IE without skin le- cialist, a cardiologist, a microbiologist, and a cardiac surgeon sions, those with dermatological manifestations had signifi- and were classified according to modified Duke criteria. cantly more extracardiac complications (75.9% vs 54.8%, Then, one of us (A.S.) examined case report forms to ex- P = .002), and their manifestations were associated with a tract information for a post hoc analysis of collected derma- higher rate of cerebral complications (41.4% vs 25.4%, P = .01), tological data. Concordance between data collection and medi-
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