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K
Spot Dx
65/M with new heart murmur, fever, and small spots on palms
Cardiology
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Case Presentation
A 65-year-old male presents with a persistent low-grade fever and weight loss over the last 4 weeks. He mentions a history of a dental extraction two months ago. On examination, a new pansystolic murmur is heard at the apex, and small, non-tender, reddish spots are seen on his palms (Janeway lesions). He also has tiny 'splinter-like' hemorrhages under his fingernails.
Question
What is the most likely diagnosis, and what is the 'gold standard' investigation required for confirmation?
Answer
The diagnosis is Subacute Infective Endocarditis. The gold standard for confirmation is the collection of three sets of blood cultures from different sites before starting antibiotics, alongside echocardiography to visualize valvular vegetations.
Clinical Pearl
The presence of a new heart murmur in a patient with unexplained fever should be considered infective endocarditis until proven otherwise; look for stigmata like Janeway lesions and splinter hemorrhages.