Clinical Cases : Man with fever and pain in hands

A 48 year old man presented with a 10 day history of intermittent fever and pain in his hands. He noticed 2 swollen and painful areas in his hands. Along with the fever, he also has weakness, malaise, watery diarrhea, weight loss, anorexia, and intermittent vomiting. He denies any other respiratory or GI symptoms. He denies any previous medical history and drug abuse.

On examination, vital signs are within normal limits. Examination of the cardiopulmonary and abdomen reveals no remarkable findings. Examination of the hand revealed 2 swollen and tender nodules on the hand.

What is the likely diagnosis ?
Hint : Consider Fever + Weakness + painful nodules

Answer : Infective Endocarditis

The painful nodules on the patient's hands are Oslers nodes. Combined with the history from the patient, it gives us the likely diagnosis of infective endocarditis.

The patient was subsequently admitted, and underwent trans-esophagial echocardiogram, which confirmed the presence of 2 distinct lesions on the aortic valve, suspicious for vegetations. He was started on a course of intravenous antibiotics.

Take home messages :

- clinical presentations of infective endocarditis may vary. Those infected with staphylococcus has higher morbidity and mortality, and typically present with high fever and cardiovascular collapse.

- Subacute bacterial endocarditis may present with fever, malaise, and other non-specific symptoms.

- The clinical presentation of infective endocarditis can occur along a continuum between acute and subacute bacterial endocarditis, hence, it is commonly overlooked because IE can present even as fever, chills, weakness, dyspnea, anorexia, malaise, nausea, and vomiting.

- Physical examination findings of IE include Osler's nodes, Janeway lesions, Roth spots, and infectious embolic complications. Oslers nodes and Janeway lesions are highly specific for IE.

- Duke's criteria is used to diagnose IE. Hence, according to the diagnostic criteria, you will have to order the following investigations : blood cultures, echocardiography, electrocardiography, and chest radiography

- Treatment will be intravenous antibiotics.

Credits to Medscape.