Osler VS Janeway

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DOI 10.1378/chest.70.2.2391976;70;239-243Chest

J B Farrior and M E Silvermaninfectious endocarditis.Janeway's lesion and an Osler's node inA consideration of the differences between a

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A Consideration of the Differences betweena Janeway's Lesion and an Osler's Node inlnf,ectious Endocard t s*JosephB. Farrior, 111, M.D ., and Mark E. Siluermun, M.D.

Janeway's lesio ns and Osler's nodes are regarded as ex- comp atible with a Janeway's lesion. The original com-cellent clues to the diagnosis of infectious endocarditis; ments by William Osler and Edward Janeway are pre-however, very few physicians have actually witnessed sented, and the literature following their descriptions isthese findings, and there is som e confusion in distinguish- reviewed. It is concluded that the only essential diagnosticing between the two. This article concerns a patient with W ere nc e between the two is the tenderness that is asso-infectious endocarditis due to Diplococcus pnarnoniac, ciated with an Osler's nod e but not with a Janeway'swh o had tender vesicular lesions thought to be Osler's lesion.nodes and a nontender erythematons nodule on the foo t

aneway7s lesions and Osier's nodes are highly ,noted. Both tympanic membranes were red and retracted;J clues to the diagnosisof infectious ende however, no pus was seen. There was moderate nuehalrigidity. The lungs were clear to auscultation and percussion.carditis that are often searched for but seldom Cardiac examination revealed a regular rhythm and sharpfound. Only a few physicians have actual- opening and closing clicks of the aortic prosthetic valve. Noly seen an Osler's node, and even fewer can clearly murmurs or gallops were heard. Laboratory results includeddistinguish an Osier's node from a Janeway7s esion. a hematocrit reading of 34 percent and a white blood cellA recent patient with infectious endocarditis and count of 8,85O/cu mm, with 81 percent neutrophils. A chestx-ray film showed clear lung fields, a normal cardiac silhouette,cutaneous lesions raised the questionas to the differ- md the aortic vah.e. A tap producedences between an Osler's node and a Janeway's lmt fluid revealing Diplococcus pneumnioe on gram stain-lesion. Our search of the current literature did not ing and culture.clearly distinguish between the two. For this reason,we believed that a review of the original descriptionand subsequent modifications mightbe of interest.

A 16-year-dd boy was admitted to Henrietta Egleston Hos-pital with meningitis and bacterial endocarditis. Two yearsprior to admission, he had undergone corrective surgery fortetralogy of Fallot an 4 in addition, had had a prostheticaortic valve inserted. One year prior to admission, the pa-tient was successfully treated for bacterernia and Schiinlein-Henoch purpura. He did well until two weeks prior to ad-mission, when he developed acute otitis media in the rightear. The patient improved with three days of therapy withcephalexin monohydrate. Two days after the therapy withcephalexin monohydrate was discontinued, he developedfever spiking to 40.6OC (105'F) associated with increasingheadaches, irritability, nausea, and vomiting.

On admission, the patient was acutely ill, with a tempera-ture of 38.3"C ( 10 l F) , a pulse of 116 beats per minute, arespiration rate of 30/min, and blood pressure of 124/90 mmHg. No petechiae or other cutaneous lesions were initially,*From the De artments of Medicine and Pediatrics, EmoryUniversity ~c$ool of Medicine, Henrietta Egleston Hospitalfor Children, and Piedmont Hospital, Atlanta.Manuscript received January 2; reiision accepted January 16.

Hospital CourseThe patient was initiany treated with 2 gm of ampicillin

and then was given 17 million units of penicillin intravenous-ly per day. He continued to have daily fever spikes in excessof 39.4'C (103F). His mental status rapidly cleared. Onthe fifth day of hospitalization, a grade 2f6 crescendo-de-crescendo systolic murmur was noted in the second rightintercostal space at the sternal edge, and a grade 1/6 earlydiastolic murmur was noted in the third left intercostal spaceof the sternal edge. No change was noted in the prostheticvalvular sounds. On the tenth day of hospitalization, threeexquisitely tender, 2 to 3-mm vesicles were noted in the padof the right index finger. Culhues and gram stained prepa-rations of the serous fluid from these lesions were negative.On the following day, the patient developed a raised 3-mmerythematous nodule of only four hours' duration in the soleof the right foot (Fi g 1) . This lesion was initially mildlytender but was ndt tender when reexamined after one hour.The lesion was associated with a fever spike to 40.5*C. Noother cutaneous lesions were noted during the rest of thepatient's hospital course. He continued to do poorly, withdaily fever spiking to 38.gC (102F). Attempts to obtainrepeated cultures while the patient was not receiving anti-biotics were negative. On the 24th day of hospitalization, hewas taken to surgery for replacement of the prosthetic valve.

CHEST, 70: 2, AUGUST, 1976 JANEWAY'S LESION AND OSLER'S NODE I N INFEC TIOUS ENDOCARDITIS 239

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FIGURE.Raised erythematous nontender area occurring onsole of right foot of our patient.This was accomplished; however, the patient died shortlyafter surgery.

Examination of the heart at autopsy revealed multipleareas of abscess formation and necrotic debris in the suturesites. Gram-positive diplococci compatible with Diplococcuspneumoniae were seen in the necrotic tissue. In addition, arupture of the membranous septum was present, allowingcommunication between the left ventricle and both rightcardiac chambers.

laneway's LesionsEdward Janeway's' original description was inthe context of separating "malignant" (acute) endo-

carditis from other infectious disorders. In an 1899article published in Medical News,' he stated:In trying to determine whether a given case is more probablydue to endocarditis or to another malignant process I havefound that attention to the position of the hemorrhages is attimes very helpful. Several times I have noted numeroussmall hemorrhages with slight nodular character in the palmsof the hand and soles of the feet, when possibly the arms andlegs had but a scanty crop in malignant endocarditis, whereasthis has not been my experience with processes likely to bemistaken for it.

Emanuel Libman: a student of Janeway, appliedthe eponym, "Janeway's lesion." Libmans.' original-ly considered these lesions to be pathognomonic foracute bacterial endocarditis but later remarked thathe had also seen them in three patients with sub-acute bacterial endocarditis. LibmanS pointed outthat this lesion was not tender, in contrast to theexquisitely painful Osler's node. A Janeway's lesionmust have been a relatively uncommon finding, for it

FIGURE. ~aneway's esion. This artist's illustration of Jane-way's lesion is reproduced from Libman and Friedberg'smonograph on subacute bacterial endocarditis published in1949 ( reproduced by permission of Oxford University Press).was not mentioned by other however, in1912, Oslers did note lesions that may have beenJaneway's lesions. He described the lesions as "pecu-liar areas of persistent erythemanson the palms andsoles in a patient with subacute bacterial endocar-ditis. These were different from the lesions he asso-ciated with infectious endocarditis that were latercalled Osler's nodes. Libman and Friedberg's9 ex-

FIGURE. Osler's node. This exquisitely tender erythematousnodule appeared on fingertip of drug addict with bicuspidregurgitation due to staphylococcal endocarditis (from Sil-verman and Hurst;'s reproduced by permission of McGraw-Hill Co., from color plate 4B, hapter 13 [General Inspection]in Hurst JW,Logue RB, Schlant RC, Wenger NK : The Heart,Arteries and Veins, 3rded, 1974).CHEST, 70: 2, AUGUST, 197640 FARRIOR, SILVERMAN



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tensive monograph on endocarditis in The OxfordMedicine of 1949 uses an artist's illustration of aJaneway's lesion (Fig 2), rather than an actualphotograph. A black-and-white photograph of onlyfair quality can be found in Kerr'slo description ofJaneway's lesion. In 1966, Cross and Ellis" pub-lished color photographs of painless irregular hem-orrhages resulting from a cutdown site infected withPseudomonas organisms; the hemorrhages were re-ported as Janeway's lesions. Libman and Friedbergsin 1949 and Friedberg12 in 1966, emphasized thefact that Janeway's lesions were infrequent, weremore characteristic of acute bacterial endocarditisthan subacute bacterial endocarditis, and werenever painful. These investigators also noted thatJaneway's lesions may appear erythematous, ratherthan hemorrhagic, in subacute bacterial endocar-ditis.

A pathologic description of a tender Janeway'slesion found among numerous nontender lesions isin Kerr'slo text on Subacute Bacterial Endocarditis.Kerrlo describes the histologic findings of the tenderlesion as a microabscess of the dermis with markednecrosis and inflammatory infiltrate not involvingthe epidermis. Cultures of a nearby area were posi-tive for Staphylococcus aureus, although no orga-nisms were seen on tissue examination of the actuallesion.Osler's Nodes

In contrast, the description of Osler's nodes (Fig3) by William Oslerls was associated with chronic(subacute) bacterial endocarditi~.~.~n his Guls-tonian. Lecture Series of 1885, Osler14 described thecutaneous manifestations of severe infectious endo-carditis as "haemorrhages . . . upon the skin, serousand mucous surfa~es,"l~(~~~nn which "a minutenecrotic or suppurative centre can sometimes be~een."'q"~~nn a 1909 issue of the QuarterlyJournal of Medicine, Osler13 reported the findingssubsequently associated with his name. Osler13 gavecredit to Dr. J. A. Mullin of Hamilton, Ontario, whobrought these lesions to his attention in 1893.1Other authors had also noted this lesion prior to1908.2~10~",13n Osler's13 report, he presents tenpatients with chronic infectious endocarditis, includ-ing seven with cutaneous lesions described as:Ephemeral spots of a painful nodular erythema chiefly in theskin of the hands and feet. . . .The spots came out at intervalsas swollen areas, some the size of a pea, others a centimetreand a half in diameter, raised,red, with a whitish point in thecenter. I have known them to pass away in a few hours butmore commonly they last for a day or even longer. Thecommonest situation is near the tip of the finger which maybe slightly swollen. . . .

F. Parkes Weber in 191315 named these findings"Osler's sign, Osler's spots or Osler's symptom,"pointing out that Osler distinguished them fromother lesions and made their signscance known togeneral medicine.Since Osler's original description, others haveadded additional clinical manifestations, such as:"painful nod~ le ;" ~preceded by painful sensation . .reddish cyanotic induration occurring within onehour of the pain;"16 "not hemorrhagic but ery-thematous and occasionally with vivid pink hue andopaque ~enter;*'~,l~deeper lesions painless or ifpainful may display few other objective ~igns;"~.'O"occasionally break down in the center and result insmall ulcer^;"^ "skin over them may desquamate butonly rarely does it ~lcerate;"~nd "erythematousarea without the formation of nodules . . . alwaystender when recent . . . even if the patient is notsensitive to pain . . . tender anemic area."sHistologically, Osler's nodes are reported to be anecrotizing vasculitis of the dermal glomus in thelower keritinous mantle, leading to congestion, ob-struction, and inflammatory infiltration of the vascu-lar channel^.^^.'^^^ Cultures of Osler's nodes havegenerally been negative. Although Osler's nodes arestrongly suggestive of bacterial endocarditis, theyhave been noted to occur in lupus erythematosu~.~Current textbook descriptions of Janeway's lesionsand Osler's nodes are given in Table 1. In a writtencommunication (April 23, 1975), Louis Weinsteinstated:While there be no difFerence histologically since both may beevidence of a vasculitis, there is a striking difference in theclinical presentation of these lesions. Clinically the Osler'snode is a painful, tender bluish-purple nodular lesion situatedin the terminal phalanges of the finger or toes. The Janeway'slesion on the other hand is a painless nontender lesion that ispink in color, irregular in shape and a macular lesion presentmore commonly on the thenar and hypothenar eminences ofthe hands and feet.

From these various descriptions and the fewpictures available, it may be U c u l t to decide ifa lesion is an Osler's node or a Janeway's lesion. Itmust be remembered that both Janeway and Oslerwere describing clinical findings which were used asdiagnostic clues to distinguish acute from subacutebacterial endocarditis, as well as from other in-fectious disorders such as typhoid and malaria. Theonly distinguishing features between the two lesionsseem to be the pain and suppuration that occur withan Osler's node and not with a Janeway's lesion.Other criteria, such as color, nodularity, size, loca-tion, and duration, are variable. Pathologically, bothlesions are described as a vasculitis with inflamma-tion and central ne~rosis.l~J'.~~similar histologic

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Table1-Textbook Deecriptiom of Janeccay'a Lesion and Oder'r NodeReference Janeway's Lesion Osler's Node

Beesonm "Painless red-blue dermal lesions on "Acute painful barely palpable nodular lesionsthe palms or soles a few millimeters in the pulps of the fingers and toes. There mayin diameter" be reddening of the overlying skin."(Not mentioned) "Pulp of the fingers may show tender

subcutaneous papules which are purplish orerythematous. Larger erythematous, painfuland tender nodules may develop on the palmsof the hand or soles of the feet."

DeGowin and DeGowinn "Erythematous or hemorrhagic macular or (Not mentioned),nodular lesions in the skin, only a fewmillimeters in diameter . . may occur inthe'palms, soles or distal par ts of the fingerpeds . . .painless and nontender . . .mayulcerate . . . crops appear for a few hoursto several days""Small erythematous or hemorrhagicleaions which are sometimes raised ornodular but never painful"

"Small 1;aised swollen areas about the .+e ofa pea, but they may be larger or small as apin-head . . . bluish tint but may be pink or redand rarely possess a blanched center. Locatedcommonly in the pads of the fingers and toes,thenar and hypothenar eminencies or soles ofthe feet-always tender"

"Painless;hemorrhagic nodular lesion found "Painful, red, indurated area usually in the padsin the palms and soles. The lesion shows a of the fingers and toes, lasting for several hoursdefinite tendency to ulcerate." to several days . . . do not ulcerate""Painless, hemorrhagic nodules in the "Small, tender, palpable erythematous lesion inpalms and soles" the pads of the fingers and toes"

description is seen in petechiae and Roth'sspot^.'^*'^^'^ Indeed, it seems that many of theperipheral clues to infectious endocarditis may bemanifestations of the same pathologic process. Al-though these lesions were initially assumed to bedue to bacterial or fibrinous emboli or to fibrin,organisms have been cultured from or near the le-sion on only rare occa~ions.~.~~he suggestion hasbeen made that the vasculitis is due to the depositionof circulating immune complexes in small blood ves-sels. This is supported by recent studies of glomeru-lonephritis associated with bacterial endocarditis.lBThe reason for the difference in appearance andsensation is unknown. Possible factors might includethe exact area of localization of the lesion, localtissue factors that tightly compartmentalize the in-flammation or allow some spread, or products re-leased by an embolus or the idlammatory reaction.Our patient displayed a cluster of exquisitelypainful intracutaneous vesicles which were probablyOsler's nodes in the suppurative phase. In addition,he had an essentially nontender erythematousnodule similar to the lesion described by Janeway.These lesions were distinctly different clinically andled us to the final conclusion that the patient hadboth Osler's nodes and a Janeway's lesion.

ACKNOWLEDGMENTS: We would like to thank Dr. BruceLogue for the opportunity to see this patient and Dr. JosephPatterson and Dr. Edward Dorney for their suggestions. Wealso acknowledge the excellent assistance of Mrs. Jane Baum-gamer and Mrs. Patricia Kirby in reviewing the literatureand preparing the manuscript

1 Janeway EG: Certain clinical observations upon heartdisease. Med News 75957-262, 1899

2 Libman E: On some experiences with blood cultures inthe study of bacterial infection. Johns Hopkins Hosp Bull17:215-228, 1906

3 Libman E: The clinical features of subacute streptococcal(and id uenzal ) endocarditis in the bacterial stage. MedClin North Am 2: 117-152, 19184 Libman E: Characterization of various forms of endocar-ditis. JAMA 80:813-818, 1923

5 Blumer G: The digital manifestations of subacute bac-terial endocarditis.Am Heart J 1 257-261, 19266 Blumer G: Remarks on subacute bacterial endocarditis.West J Surg Obstet Gynecol49:406-416, 1941

7 Shenebourne EA, Cripps GM, Hayward GW, et al : Bac-terial endocarditis 1956-1965: Analysis of clinical featuresand treatment in relation to prognosis and mortality. BrHeart J 31 536-542, 1969

8 Osler W: Chronic infectious endocarditis with an earlyhistory like splenic anemia. Interstate Med J 19:103-107,1912

9 Libman E, Friedberg CK: Subacute bacterial endocardialdiseases of the heart, blood vessels, and blood. I n Chris-

242 FARRIOR, SILVERMAN CHEST, 70: 2, AUGUST, 1976



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tian H: The Oxford Medicine (2nd ed) . New York,Oxford University Press, 1949, vol2, pp 34-36

10 Kerr A : Subacute Bacterial Endocarditis. Springfield, 111,Charles C Thomas Co, 1955, pp 101-116

11 Cross DE, Ellis JG: Occurrence of the Janeway lesion inmycotic aneurysm. Arch Intern Med 118:588-591, 1966

12 Friedberg CK: Endocarditis and endocardia] disease. InFriedberg CK: Diseases of the Heart (3rd ed ) . Phila-delphia, WB Saunders Co, 1966, pp 1388-1389

13 Osler W: Chronic infectious endocarditis. Q J Med 2:219-230, 190914 Osler W: Gulstonian lectures on malignant endocarditis.Lancet 1:415-418, 459464, 505-508, 1885

15 WeEer FP: "Osler's sign" and certain cutaneous phenom'-ena sometimes associated with heart disease. Q J Med4:384-390, 1913

16 Von Gemmengen GR, Winkelmann RK: Osler's nodes ofsubacute bacterial endocarditis. Arch Dermatol 95:91-94,1967

17 Kennedy JE, Wise GN: Clinicopathologic correlation ofretinal lesions, subacute bacterial endocarditis. ArchOphthalmol 74:658-662, 1965

18 Ruiter M, Mandema E : New cutaneous syndrome insubacute bacterial endocarditis. Arch Intern Med 113:283-290, 1964

19 Gutman RA, Striker GE, Gilliland BC, et al : The immunecomplex glomemlonephritis of bacterial endocarditis.Medicine 51: 1-125, 1972

20 Beeson PB: Bacterial endocarditis. In Beeson PB, Mc-Dermott W (eds ) : Cecil-Loeb Textbook of Medicine( 13th ed ). Philadelphia, WB Saunders Co, 1971, pp 1098-1106

21 Cluff LE: Bacterial endocarditis. In Wintrobe MN, ThornGW, Adams RD, et a1 (e ds ): Harrison's Principles ofInternal Medicine (7t h ed) . New York, McCraw-HillBook Co, 1974, p 76322 DeGowin EL, DeGowin RL: Bedside Diagnostic Exami-nation. New York, Macmillan Publishing Co, Inc, 1969, p653

23 Dorney ER: Endocarditis. In Hurst JW, Logue RB,Schlant RC, et al (e ds ): The Heart, Arteries and Veins(3rd ed ) . New York, McCraw-Hill Book Co, 1974, pp1290-1304

24 Kaplan S: Diseases of the endocardium. In Nelson WE( ed ) : Textbook of Pediatrics ( 9th ed ) .Philadelphia, WBSaunders Co, 1969, pp 1022-1023

25 Silverman ME, Hurst JW: Inspection of the patient. InHurst JW, Logue RB, Schlant RC, et a1 ( eds): TheHeart, Arteries and Veins (3rd ed ). New York, McCraw-Hill Book Co, 1974, chap 13, plate 4B

EthologyIt is also both scientifically legitimate and operational-

ly necessary to ascribe mind to highest animals. This isobvious as regards the anthropoid apes: they not onlypossess very similar bodies a nd sense-organs to ours, bu talso manifest similar behavior, with quite a similarrange of emotional expression; a range of curiosity,anger, alertness, affection, jealousy, fear, pain and plea-sure. This is obvious as regards the anthropoid apes. It isequally legitimate and necessary for other mammals,although the similarities are not so close. We cannotbegin to understand or interpret the behavior of ele-

phants or dogs or cats or porpoises unless we do so tosome extent in mental terms. This is not anthropo-morphism: it is merely an extension of the principles ofcomparative study that have been so fruitful in compara-tive anatomy, comparative physiology, comparativecytology and other biological fields. It is equally fruitfulwhen you extend it to the stud y of animal behavior, thisrapidly developing modern branch of science which iscalled ethology.

Huxley, JS: Essays of a Humani st, New YorklHarper & Row, 1964

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DOI 10.1378/chest.70.2.2391976;70; 239-243Chest

J B Farrior and M E Silvermannode in infectious endocarditis.

A consideration of the differences between a Janeway's lesion and an Osler's

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