Splinter Hemorrhage - A Clue for Infective Endocarditis

Introduction:

Splinter hemorrhages are small, linear, tiny blood splinters under the nails in the fingers and toe, often associated with trauma and infection but can also indicate various underlying medical conditions, including infective endocarditis. Therefore, splinter hemorrhages in an individual, accompanied by other symptoms like fever, heart murmurs, and systemic signs of infection, can raise suspicion for infective endocarditis. However, it is important to note that splinter hemorrhages can also occur in other conditions or even as a result of trauma, so their presence alone is not diagnostic of infective endocarditis but rather serves as a clue for further investigation, especially if they recur or are accompanied by other symptoms.

What Are the Other Names for Splinter Hemorrhage?

Splinter hemorrhages are also known by several other names, including:

• Linear hemorrhages.

• Fingernail hemorrhages.

• Subungual hemorrhages.

• Blood spots under nails.

• Nail bed hemorrhages.

• Longitudinal hemorrhages.

These terms are often used interchangeably to refer to the same condition where small areas of bleeding occur underneath the fingernails or toenails.

How Do Splinter Hemorrhages Appear?

• Splinter hemorrhages appear as reddish-brown streaks under the nails, running in the direction of the nail growth.

• They typically resemble thin splinters or lines of blood trapped beneath the nail plate.

• They may be asymptomatic and tender.

• These hemorrhages are about one to three millimeters in width and can vary in length, ranging from a few millimeters to the entire length of the nail bed.

• Splinter hemorrhages may be single or multiple, affecting one or multiple nails.

• They are most commonly seen under the fingernails but can also occur under the toenails.

What Could Be the Cause of Splinter Hemorrhage?

Splinter hemorrhages can be caused by various factors, including:

• Trauma: Injury to the nail bed or nail matrix can occur from activities such as vigorous nail-biting, hitting the nails against hard surfaces, or wearing tight-fitting shoes.

• Infective Endocarditis: As mentioned before, infective endocarditis, an infection of the heart valves, can lead to the formation of small blood clots that are trapped under the nails, causing splinter hemorrhages.

• Vascular Disorders: Conditions affecting blood vessels, such as vasculitis (inflammation of blood vessels), can cause damage to the tiny blood vessels under the nails, resulting in splinter hemorrhages.

• Systemic Diseases: Certain systemic diseases, including autoimmune disorders like lupus erythematosus and conditions like psoriasis (flaky patches of the skin), can be associated with splinter hemorrhages.

• Medications: Some medications, particularly those that affect blood clotting or blood vessel integrity, may contribute to the development of splinter hemorrhages as a side effect.

• Fungal Nail Infections: Infections of the nails, such as onychomycosis (fungal nail infection), cause damage to the nail bed and surrounding blood vessels, leading to splinter hemorrhages.

• Microemboli: Small emboli or tiny blood clots or debris that travel through the bloodstream and lodge in the small blood vessels under the nails, resulting in splinter hemorrhages.

How Is Splinter Hemorrhage Related to Infective Endocarditis?

• Infective endocarditis is typically caused by bacteria or other infectious agents that enter the bloodstream and lodge on the heart valves or the inner lining of the heart chambers.

• These bacteria can cause damage to the heart tissue, leading to the formation of vegetation (clumps of bacteria, fibrin, and platelets).

• These vegetations can then break off, forming emboli that travel through the bloodstream.

• When the septic emboli reach small blood vessels under the nails, they can cause tiny blood clots, resulting in splinter hemorrhages.

• Splinter hemorrhage does not directly contribute to infective endocarditis, but it is a potential symptom of infective endocarditis.

• Thus, splinter hemorrhages can sometimes serve as an indicator of infective endocarditis, prompting further investigation and treatment to address the underlying infection and prevent potential complications.

• In the case of infective endocarditis and splinter hemorrhage, prioritising treatment depends on various factors such as the severity of symptoms, the underlying cause of the conditions, and individual patient circumstances.

• Generally, infective endocarditis is considered a more serious condition as it involves infection of the heart valves, which can lead to severe complications such as heart failure or stroke.

• Therefore, treating infective endocarditis would typically take precedence over addressing splinter hemorrhages.

How Is Splinter Hemorrhage Managed?

• There is no specific treatment for splinter hemorrhage caused by trauma.

• Nails grow at a slow pace, so it takes several months for a hemorrhage to heal.

• If having pain after injury, apply a cold compress to reduce the inflammation and swelling.

• Also, take over-the-counter painkillers to alleviate the symptoms.

• If splinter hemorrhage occurs due to an underlying disease, then the disease must be treated to prevent the bleeding.

• Treatment usually involves addressing the underlying cause, such as treating an infection if present and allowing the nail to grow out.

• For instance, the healthcare provider may prescribe certain antifungals or antibiotics to treat the underlying cause.

• In some cases, immunosuppressants can also be prescribed.

How Will the Prognosis Be?

• The outcome is positive in cases of traumatic splinter hemorrhage. When the nail grows, the hemorrhage clears up.

• When accompanied by underlying conditions, withdrawing certain medications as suggested by the healthcare provider may improve the symptoms.

• Living with infective endocarditis and splinter hemorrhages can be challenging, as both conditions require proper management and monitoring to prevent complications.

• Individuals with infective endocarditis may need to make lifestyle changes to reduce the risk of further complications. This can include practicing good dental hygiene to prevent oral infections, avoiding intravenous drug use, and adhering to any prescribed medication regimens.

• After initial treatment, regular follow-up appointments with a healthcare provider are essential to monitor the progress of the infection, assess heart function, and prevent recurrence.

Conclusion:

Splinter hemorrhages are small areas of bleeding underneath the fingernails or toenails. They are often caused by trauma or injury to the nail bed. Treatment usually involves addressing the underlying cause, such as treating an infection if present and allowing the nail to grow out. In most cases, splinter hemorrhages will resolve on their own without specific treatment. However, it is best to consult a healthcare professional for proper evaluation and management if they are recurrent or associated with other symptoms.