a)    List six clinical signs on examination that would support the diagnosis of infective endocarditis in a patient with fever and a new murmur.     (30% marks) 

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College answer

•    Janeway lesions (small, non-tender erythematous or haemorrhagic macular or nodular lesions on the palms or soles) 
•    Roth spots (retinal haemorrhages with pale or white centres) 
•    Oslers nodes (painful, red raised lesions found on the hands and feet)  
•    Splinter haemorrhages  
•    Clubbing  
•    Splenomegaly  
•    Petechiae 
 

Discussion

This question, and the college answer, are identical to  Question 29.1 from the second paper of 2014.

An excellent review article form 2009 lists the following clinical features:

  • Osler's nodes
  • Janeway lesions
  • Splinter haemorrhages
  • Roth spots
  • Focal neurological signs suggestive of embolic phenomena
  • A new murmur or a worsening of an old murmur
  • Splenomegaly
  • Glomerulonephritis
  • Arthralgia and arthritis
  • Elevated ESR, CRP or rheumatoid factor
  • Haematuria

The abovementioned article has a table (Table 3) which lists these manifestations according to their prevalence among a large patient cohort. The emphasis of the article is on endocarditis "in the 21st century", implying that the endocarditis of the previous centuries was substantially different. This is certainly true. One need only refer to the 1885 Gulstonian Lectures by William Osler to see what infective endocarditis looked like in the pre-antibiotic era (in short, it was uniformly fatal). For a relatively recent 20th century perspective, one can turn to a 1983 review of the state-of-the art diagnosis and therapy for the previous 25 years.

References

Murdoch, David R., et al. "Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis–Prospective Cohort Study." Archives of internal medicine 169.5 (2009): 463-473.

Richardson, JAMES V., et al. "Treatment of infective endocarditis: a 10-year comparative analysis." Circulation 58.4 (1978): 589-597.

Windsor, HARRY M., and MARK X. Shanahan. "Emergency valve replacement in bacterial endocarditis." Thorax 22.1 (1967): 25-33.

Yu, Victor L., et al. "Prosthetic valve endocarditis: superiority of surgical valve replacement versus medical therapy only." The Annals of thoracic surgery 58.4 (1994): 1073-1077.

Brandenburg, Robert O., et al. "Infective endocarditis—a 25 year overview of diagnosis and therapy." Journal of the American College of Cardiology 1.1 (1983): 280-291.

Pruitt, R. D. "William Osler and his Gulstonian Lectures on malignant endocarditis." Mayo Clinic Proceedings. Vol. 57. No. 1. 1982.

Kang, Duk-Hyun, et al. "Early surgery versus conventional treatment for infective endocarditis." New England Journal of Medicine 366.26 (2012): 2466-2473.

Thuny, Franck, et al. "Management of infective endocarditis: challenges and perspectives." The Lancet 379.9819 (2012): 965-975.