Internal Medicine case: infective endocarditis — Osler nodes, conjunctival petechiae; key clues and immediate diagnostic steps for IM clinicians.
Quick clinical clue question on suspected infective endocarditis—focuses on murmur changes, peripheral stigmata, and how Duke criteria guide diagnostic certainty in febrile patients.
Findings are most consistent with infective endocarditis. Obtain blood cultures promptly, arrange echocardiography (TTE → TEE if high suspicion), and consult ID/cardiology while considering empiric IV antibiotics.
A 54-year-old man presents to his physician’s office with the complaint of fever of 2 weeks duration. His temperature has varied between 101° and 103°. He has had no chills, cough, or urinary symptoms. Over the past few days, he has had painful “lumps” on the toes of his feet.
Figure 1. Osler Node
Figure 2. Conjunctival Petechiae
Examination of the heart reveals a Grade III holosystolic murmur at the apex. It is noted to be louder than previously recorded. The remainder of the physical examination is normal.
Which of the following essentially confirm a diagnosis of bacterial endocarditis in this febrile patient?
Answer Options:
The correct answer is #1.
– Learners focus on “classic” findings (Osler nodes, Janeway lesions) and overlook that a new or changed murmur is a major Duke criterion, whereas Osler nodes are only minor.
– Conjunctival petechiae are subtle and often mistaken for nonspecific irritation, yet they count as a vascular (minor) criterion.
| Option | What It Tests / Implies | Why It’s Wrong Here |
|---|---|---|
| Osler nodes and fever | Immunologic phenomena + general sign | Both are Duke minor criteria – two minors alone don’t confirm definite IE. |
| Osler nodes and vascular emboli | Immunologic + vascular phenomena | Two minor criteria; still insufficient for “definite” endocarditis. |
| Fever and vascular emboli | Fever + vascular phenomena | Again, two minor criteria without any major criterion. |
| Worsening of a pre-existing murmur and conjunctival petechiae | New regurgitation (major) + vascular phenomenon (minor) | Only combination here with ≥1 major criterion → confirms definite IE. |
A changing or new regurgitant murmur is a major Duke criterion—pair it with any vascular or immunologic sign, and you’ve clinched the diagnosis.
This item hinges on knowing that only new valve regurgitation (a major criterion) combined with a single minor criterion is enough for a definite IE diagnosis—many distractors use two minors (Osler, fever, emboli) which are tempting but insufficient.
A 58-year-old IV drug user has had 2 weeks of fever, blood cultures positive for S. aureus, and a newly detected holosystolic murmur at the apex. Which combination meets definite IE by Duke criteria?
A. Positive blood cultures + new regurgitant murmur
B. Positive blood cultures + splinter hemorrhages
C. Fever + Janeway lesions
D. Osler nodes + Janeway lesions
A 62-year-old with suspected endocarditis has tender nodules on fingertips and painless, flat erythematous macules on palms and soles. Which pairing correctly classifies them?
A. Janeway lesions = immunologic; Osler nodes = vascular
B. Osler nodes = immunologic; Janeway lesions = vascular
C. Janeway lesions = immunologic; splinter hemorrhages = vascular
D. Splinter hemorrhages = immunologic; Janeway lesions = vascular
Which of the following combinations represents one major and one minor Duke criterion?
A. New regurgitant murmur + Osler nodes
B. New regurgitant murmur + conjunctival petechiae
C. Fever + Janeway lesions
D. Positive echo showing vegetation + Osler nodes
Discuss how immunologic phenomena (Osler nodes, Roth spots) versus vascular phenomena (Janeway lesions, petechiae) reflect different pathophysiologic mechanisms in infective endocarditis, and how recognizing each influences both diagnosis and management.
This question appears in Med-Challenger Internal Medicine Review with CME
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