Osler's nodes, Janeway lesions and splinter haemorrhages.

To cite: Hirai T, Koster M. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2013-009759 DESCRIPTION A 22-year-old man with a history of intravenous heroin misuse, presented with 1 week of fatigue and fever. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Physical examination showed multiple painful 1– 2 mm macular rashes on the palm and soles bilaterally (figures 1 and 2). Splinter haemorrhages (figure 3) and conjunctival petechiae (figure 4) were also noted. A transoesophageal echocardiogram demonstrated a 16-mm vegetation on the mitral valve (figure 5). Vegitations >10 mm in diameter and infection involving the mitral valve are independently associated with an increased risk of embolisation. However, he decided medical management after extensive discussion and was treated with intravenous nafcillin for 6 weeks. He returned 8 weeks later with acute shortness of breath and evidence of a perforated mitral valve for which he subsequently underwent a successful mitral valve repair with an uneventful recovery.