Splinter Hemorrhages

The patient is a 48 year-old woman with a two week history of splinter hemorrhages in all ten finger nails.  Her toe nails are obscured with nail polish.  She has a history of appendiceal cancer, has had two surgeries and is left with residual disease.  She is being treated with leucovoran, avastin and 5FU.  She feels well.  No fever, chills or night sweats.  She has had recent normal cardiac echos.

Diagnosis and Discussion:  It's hard not to conclude that these are typical splinter hemorrhages and that she needs to be worked up for subacute bacterial endocarditis.  Some antineoplastic agents, such as paclitaxel, can cause splinter hemorrhages but I could find not reference to the drugs she is on.  The splinter hemorrhages of SBE are more often proximal and all of these are distal, arguing for a relationship with her chemotherapy; but appropriate blood cultures seem indicated.