Cases from the Osler Medical Service at Johns Hopkins University

Presenting features A 29-year-old woman with a history of rheumatic heart disease and one episode of endocarditis as an adolescent was admitted to the hospital after 1 week of headache, fever, and myalgia. Her past medical history was otherwise unremarkable and did not include illicit drug use. On physical examination, she had a previously noted 3/6 holosystolic murmur at the apex, which radiated to her back; a previously noted 1/4 diastolic murmur at the right upper sternal border; diminished strength in her right upper extremity; multiple painful erythematous nodules on her fingers (Figure 1); and red streaks under her nails (Figure 2). Magnetic resonance imaging of the brain demonstrated multiple lesions; the largest was in the right frontal lobe with associated hemorrhage (Figure 3). Figure 1. Erythematous nodules in the hand and the pulp of the fingertips (arrows). Figure 2. Red streaks in the middle portion of the nail bed (arrow). Figure 3. Magnetic resonance imaging of the brain showing multiple infarctions with an area of superimposed hemorrhage in the right frontal lobe (arrow). What is the diagnosis?