Janeway lesions

Description

Janeway lesions are non-tender, small erythematous or haemorrhagic macular or nodular lesions on the palms or soles only a few millimeters in diameter that are indicative of infective endocarditis. To be differentiated from painful Osler nodes.

History

1899 – Edward Janeway described the lesion in the context of separating “malignant” (acute) endocarditis from other infectious disorders

In trying to determine whether a given case is more probably due to endocarditis or to another malignant process I have found that attention to the position of the hemorrhages is at times very helpful. Several times I have noted numerous small hemorrhages with slight nodular character in the palms of the hand and soles of the feet, when possibly the arms and legs had but a scanty crop in malignant endocarditis, whereas this has not been my experience with processes likely to be mistaken for it.

Janeway, 1899

Emanuel Libman (1872 – 1946), a student of Janeway, applied the eponym ‘Janeway lesion’. Libman pointed out that this lesion was not tender, in contrast to the exquisitely painful Osler node.

I would like to refer to a point which has been of great value… “the small hemorrhages in the palms and soles with slightly nodular character” I learned from Dr. Janeway when I had the privilege of serving under him…(keep) a sharp lookout for them as they will often direct attention to an acute endocarditis to which there was no other clue.

Libman, 1906

1912 – Sir William Osler (1849 – 1919) recorded lesions that may well have been Janeway lesions. He described the lesions as “peculiar areas of persistent erythema” on the palms and soles in a patient with subacute bacterial endocarditis [1912; 19: 103-107]. These were in stark contrast to the painful erythematous nodules he associated with infectious endocarditis that were later termed Osler nodes.

1923 – Libman originally considered Janeway lesions to be pathognomonic for acute bacterial endocarditis but later remarked that he had also seen them in three patients with subacute bacterial endocarditis.

Embolic lesions occur with great frequency in the acute and subacute bacterial cases. They consist of petechiae, Janeway lesions, Osler (tender cutaneous) nodes and purpura

Libman, 1923:815

1949 – Libman and Friedberg emphasized the fact that Janeway lesions were infrequent; more characteristic of acute bacterial endocarditis than subacute bacterial endocarditis; and were never painful. They noted that Janeway lesions may appear erythematous, rather than hemorrhagic, particularly in subacute bacterial endocarditis

1976 – Joseph B. Farrior, III evaluation of ‘classic‘ textbook descriptions of Janeway lesions and Osler nodes

Associated Persons

• Edward Gamaliel Janeway (1841 – 1911) [Janeway lesion]
• Emanuel Libman (1872 – 1946)
• Sir William Osler (1849 – 1919) [Osler nodes]

References

• Janeway EG. Certain clinical observations upon heart disease. Medical News. 1899; 75: 257-262
• Libman E. On some experiences with blood cultures in the study of bacterial infection. Johns Hopkins Hospital Bulletin. 1906; 17: 215-228
• Osler W. Chronic infectious endocarditis with an early history like splenic anemia. Interstate Medical Journal 1912; 19: 103-107
• Libman E. The clinical features of subacute streptococcal (and influenzal) endocarditis in the bacterial stage. Medical Clinics of North America 1918; 2(1): 117-152
• Libman E. Characterization of various forms of endocarditis. JAMA 1923; 80: 813-818
• Farrior JB, Silverman ME. A consideration of the differences between a Janeway’s lesion and an Osler’s node in infectious endocarditis. Chest. 1976 Aug;70(2):239-43.
• Marrie TJ. Osler’s nodes and Janeway lesions. Am J Med. 2008 Feb;121(2):105-6
• Sethi K, Buckley J, de Wolff J. Splinter haemorrhages, Osler’s nodes, Janeway lesions and Roth spots: the peripheral stigmata of endocarditis. Br J Hosp Med (Lond). 2013 Sep;74(9):C139-42.
• Misin A, Di Bella S, Priolo L, Luzzati R. Image of the month: ‘Diagnostic hands’: Janeway lesions. Clin Med (Lond). 2017 Jul;17(4):373-374