A 30-year old patient having a history of rheumatic fever during adolescence, presented with high grade fever and erythematous lesion on both palms. On echocardiography, the cardiologist detects small sterile vegetations along line of closure of the mitral valve. Which of the following is least likely to be found in this patient?

The patient is suffering from infective endocarditis. With a background of rheumatic fever, the likely risk factor for IE in this case is rheumatic hea disease (RHD). Some of the clinical features of infective endocarditis related to microthromboemboli include erythematous or hemorrhagic nontender lesions on the palms or soles (Janeway lesions), subcutaneous nodules in the pulp of the digits (Osler nodes), and retinal hemorrhages in the eyes (Roth spots). Subendocardial lesions in RHD, exacerbated by regurgitant jets, can induce irregular thickenings called MacCallum plaques, usually in the left atrium. Aschoff bodies are rarely seen in surgical specimens or autopsy tissue from patients with chronic RHD, because of the long intervals between the initial insult and the development of the chronic deformity. Aschoff bodies and Anitschkow cells are seen in acute rheumatic fever.