A 65-year-old man presented to the emergency department complaining of 1-month history of back pain. He also noted fatigue, night sweats, blurry vision and 10 Ib weight loss. He recalls dental cleaning recently, but denied any other medical history. He was afebrile and hemodynamically stable. Physical examination showed non-tender maculopapular rash on his palm, finding consistent with Janeway lesions (Figure 1A, arrow). Cardiac examination revealed 3/6 diastolic murmur at the left sternal border. He had pain in the left sacroiliac joint with no paraspinal tenderness. Labs showed leukocytosis and anemia.
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