Janeway Lesion – Dermoscopy as an Adjunctive Tool

A 13-year-old boy was admitted with high-grade fever, skin rashes, and altered sensorium. Examination revealed multiple nontender hemorrhagic macules on palms and soles [Figure 1a and b]. Differential diagnoses included Janeway lesions, cutaneous microembolism, and cutaneous small vessel vasculitis (CSVV). Dermoscopy showed mottled purpuric dots on a pinkish background in early lesions, circular heterogeneous purpuric background with peripheral brown blotches in late lesions, and yellowish structureless areas at the center with peripheral brown and red-purple globules in resolving lesions [Figure 2a and b]. Red globules and blotches in a mottled distribution on a milky-red background expected in CSVV lesions were not documented.[1] Dermoscopic features presumed in cutaneous microembolism are those of an inflammatory purpura as mentioned above.[2,3]Figure 1: (a) Multiple hemorrhagic macules on palms (blue arrow) and artifact due to mehendi (red arrow) (b) Circular hemorrhagic macule on the big toeFigure 2: Dermoscopy (a) Early lesion with mottled purpuric dots on a pinkish background (blue arrows), late lesion with circular heterogeneous purpuric background with brown blotches (green arrows), adjacent resolving lesion with yellowish structureless area at the center (red arrow), and peripheral brown globules (yellow arrow). (DermLite DL4, polarized mode, 10×) (b) Another resolving lesion showing yellowish structureless areas at the center (red arrow) with red-purple globules (black arrow). (DermLite DL4, polarized mode, 10×)Investigations revealed Roth spots on ophthalmoscopy, mitral valve vegetations on echocardiography, and large middle cerebral artery infarct on radiographic imaging. The presence of vegetations on echocardiography with lack of an identifiable source of emboli ruled out the possibility of cutaneous microembolism.[2] Janeway lesions are a part of minor diagnostic criteria for infective endocarditis, described as painless hemorrhagic macules or papules typically observed on palms and soles.[4] Histopathology reveals dermal septic emboli with neutrophilic microabscess indicating inflammatory pathology. Mottled purpuric pattern on dermoscopy is suggestive of an inflammatory purpura as opposed to noninflammatory homogeneous pattern.[3] Mottled purpuric dots and red-purple globules histologically correspond to extravasated erythrocytes at various stages cuffed by inflammatory cells, yellowish structureless areas to dermal siderophages, and brown globules or blotches correspond to hemosiderin deposits from extravasated erythrocytes.[1,3] Declaration of patient consent The authors certify that they have obtained all appropriate parent consent forms. In the form, the parent has given their consent for his images and other clinical information to be reported in the journal. The parent understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Use of artificial intelligence (AI) We have not used artificial intelligence in preparation of manuscript.