Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2025;15(4):5816 1 A Case of Infective Endocarditis Presenting with Skin Findings Zeynep Busra Balik1, Gulsen Akoglu1 1 Health Sciences University Gülhane Training and Research Hospital Department of Dermatology and Venereology, Ankara, Turkey Key words: Infective Endocarditis, Janeway Lesions, Skin Findings Citation: Balik ZB, Akoglu G. A Case of Infective Endocarditis presenting with Skin Findings. Dermatol Pract Concept. 2025;15(4):5816. DOI: https://doi.org/10.5826/dpc.1504a5816 Accepted: April 22, 2025; Published: October 2025 Copyright: ©2025 Balik et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Zeynep Büşra Balık, Health Sciences University Gülhane Training and Research Hospital Department of Dermatology and Venereology, General Dr. Tevfik Saglam Caddesi, No:1 Post Code: 06010 Etlik, Keçiören, Ankara. ORCID ID: 0000-0003-3578-3511. Email: zeynepbusrakucuker@gmail.com Introduction This case is shared to remind dermatologists of derma- tological findings in rapid and accurate diagnosis and the importance of Janeway lesions in the diagnosis of infective endocarditis (IE) and to contribute to the literature. Case Presentation A 40-year-old male presented to the emergency department with complaints of weakness, diffuse muscle aches, yellow- ing of the eyes, and burning during urination for a week. Shortly before his admission, he had noticed non-painful dis- coloration of the big toe of the left foot, the third finger nail of the right hand, the distal tips of the fingers, and bilateral palmar areas. Cardiovascular and respiratory system exam- ination was normal. He had no fever. Blood pressure, pulse, and O2 saturation were normal. WBC:20.29x103 cells/µL, PLT:60x103 cells/µL were measured as abnormal findings. Elevated liver enzymes (AST: 510 U/L, ALT: 359 U/L, ALP: 238 U/L, Total Bilirubin: 6.21 mg/dL, Direct Bilirubin: 4.68 mg/dL, LDH: 798 U/L, GGT: 77 U/L) were detected. Renal function tests showed deterioration (Creatinine: 4.1 mg/dl, Urea: 160 mg/dl, GFR: 17). CRP:380 mg/L and Procalci- tonin:2.1 ng/mL. The patient was admitted to the intensive care unit due to acute renal failure, elevated liver enzymes, and acute phase reactants. Cholestatic appearance was ob- served on abdominal USG. The patient’s blood culture result was negative. Hepatitis panel, ANTI HIV, Torch panel, EBV, VZV, Leptospirosis, and Crimean-Congo haemorrhagic fever antibodies were negative. During follow-up, the patient de- veloped persistent fever and agitation, and his general condi- tion and laboratory values deteriorated rapidly. The patient was evaluated neurologically, and no neurologic pathology was considered. Skin biopsy was taken from the livedo mac- ular and papular lesions (Figure 1) of the patient, who was consulted dermatologically. Histopathological evaluation revealed perivascular and periadnexal nonspecific lympho- cytic dermatitis in the upper, middle, and deep dermis. The patient was evaluated by the rheumatology and cardiology clinics, and fibrinogen: 657 mg/dL, D-dimer: 4.44 mg/L, procalcitonin: 6.2 ng/mL and NTProBNP: 4458 pg/mL 2 Research Letter | Dermatol Pract Concept. 2025;15(4):5816 values gradually increased. Subsequently, a transesophageal echocardiogram (TEE) was performed. Although no veg- etation was detected on the initial transthoracic echocar- diogram (TTE), the TEE revealed an 8-mm mass/vegetation involving all three cusps, more prominent on the noncoro- nary and right coronary cusps of the aortic valve. Conclusion In this case, the patient was diagnosed with IE relatively late as pre-diagnoses such as viral hepatitis, cholecystitis, and urinary tract infection were prioritized due to the absence of fever and cardiac symptoms/signs at the beginning and to the absence of growth in multiple blood cultures, although the patient’s skin findings were a warning. Janeway lesion is a cutaneous manifestation of endocarditis, a disease usually caused by bacterial or fungal infection of the cardiac endo- cardium. Janeway lesions are irregular, nontender, erythem- atous or hemorrhagic macules or papules lasting days to weeks, usually found on the palms and soles of the feet [1]. It should be kept in mind that Janeway lesions may be an important clue for early diagnosis of IE. Reference 1. Murdoch DR, Corey GR, Hoen B, et al. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st cen- tury: the International Collaboration on Endocarditis-Prospec- tive Cohort Study. Arch Intern Med 2009;169(5): 463-473. DOI: 10.1001/archinternmed.2008.603. PMID: 19273776 Figure 1. Janeway lesions: Subungal, irregular, painless, erythema- tous or hemorrhagic macules and papules on the left big toe, palms, and distal tips of fingers.