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Atypical case of infective endocarditis
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Other responses

  • Published on:
    In response to: It is important to check nails, fingers, palms, planters, conjunctivae, oral mucosa, and optic fundi.
    • Abraham M Ittyachen, Professor of Medicine` Malankara Orthodox Syrian Church Medical College and Hospital

    Regarding the question raised by Dr. Yasuharu Tokuda, Consultant Physician; as rightly pointed out by Dr. Tokuda it is important to look for peripheral signs of IE. We did look for these signs but could not find any. Besides, though many peripheral signs are described in IE, the actual incidence is very low.

    Dr. Ittyachen.

    Conflict of Interest:
    None declared.
  • Published on:
    It is important to check nails, fingers, palms, planters, conjunctivae, oral mucosa, and optic fundi.
    • Yasuharu Tokuda, Consultant Physician Muribushi Okinawa Center for Teaching Hospitals

    The diagnostic excellence of infective endocarditis (IE) requires careful physical examination. In the current case reported by Ittyachen et al, a diagnosis of IE was made on Day 6 of hospitalization. However, no visualization of vegetation by transthoracic echocardiography, especially on Day 1, is common because of its low sensitivity (1). Patients with acute heart failure along with mitral regurgitation need rapid diagnostic evaluation for possibility of IE.

    There were no documentation for physical findings as important signs of IE except cardiac murmur and oral hygiene. The accurate diagnosis based on physical diagnosis might have been achieved earlier if a high index of suspicion for IE with careful examination had been considered. I always recommend checking nails, fingers, palms, planters, conjunctivae, oral mucosa, and optic fundi in suspected cases of IE. The list to search should include splinter hemorrhage, Osler node, Janeway purpura, mucosal petechiae, and Roth spot (2).

    Yasuharu Tokuda, MD MPH
    Consultant Physician and Director
    Muribushi Okinawa Center for Teaching Hospitals, Urasoe City, Okinawa, Japan.


    (1) Baddour LM, et al; American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. Infective Endocarditis in Adults: Diagn...

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    Conflict of Interest:
    None declared.