Austrian Syndrome: A Rare and Unfortunate Triad

Abstract

SESSION TITLE: Student/Resident Case Report Poster - Critical Care III SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Austrian syndrome consists of a triad of meningitis, pneumonia, and endocarditis due to Streptococcus pneumoniae. We present an unusual case of this rare diagnosis. CASE PRESENTATION: A 61 year old female with history of alcohol abuse was brought to the emergency department after family found her unresponsive. On arrival to the emergency department, blood pressure was 73/42 mmHg, pulse 108 bpm, temperature 102.6 F, and respiratory rate 38/min. Physical exam was notable for coarse bilateral rhonchi on lung exam and a new, harsh pansystolic murmur. Laboratory studies showed a leukocyte count of 21,000 mm3, lactate 7 mmol/L, and creatinine 2.7 mg/dL. Troponin was 0.1 ng/dL and ECG showed sinus tachycardia with no ST-T changes. An arterial blood gas showed pH 6.75, pCO2 31 mmHg, pO2 60 mmHg, and bicarbonate 4 mEq/L. Chest x-ray showed bibasilar atelectasis and probable right lower lobe consolidation. Lumbar puncture released purulent cerebrospinal fluid. HIV and hepatitis screens were negative. The patient had a cardiac arrest due to severe metabolic acidosis with return of spontaneous circulation after cardiopulmonary resuscitation. She was intubated for respiratory failure and started on therapeutic hypothermia. Due to high suspicion for bacterial meningitis, patient was started on Ceftriaxone, Ampicillin, and Vancomycin. Blood, respiratory, and cerebrospinal fluid cultures grew S. pneumoniae. Trans-thoracic echocardiogram revealed severe mitral regurgitation and aneurysmal basal and inferolateral segments of the left ventricle - new findings compared to prior echocardiogram. The patient remained in refractory shock and developed multiorgan failure. Her family elected to withdraw care. She was extubated compassionately and passed away shortly thereafter. DISCUSSION: Austrian syndrome occurs in only about 1.2% of all patients with infective endocarditis. It is most commonly seen in elderly males with history of alcohol abuse, immunocompromised state, or recent valve surgery. Although our patient did not have a transesophageal echocardiogram to confirm vegetations, the presence of new valvular insufficiency and left ventricular aneurysm without evidence of myocardial infarction provide enough evidence of endocarditis. Lumbar puncture confirmed meningitis and respiratory cultures confirmed pneumonia. Our patient received adequate resuscitation and broad spectrum antibiotics when hospitalized, but due to delay in making the diagnosis, she did not survive. Recommended treatment is early antibiotic therapy and valvular repair. CONCLUSIONS: Austrian syndrome carries a 60% mortality rate if not diagnosed early. Therefore, in patients with pneumococcal infection and predisposing risk factors, clinicians should carry a high index of suspicion for this rare but life threatening phenomenon. Reference #1: Poulsen, J B et al. “Austrian Syndrome.” BMJ Case Reports 2011 (2011): bcr0920103368. PMC. Web. 5 Apr. 2016. DISCLOSURE: The following authors have nothing to disclose: Maria Benoy, Qamar Ahmad, Farrukh Abbas, Michael Gurell No Product/Research Disclosure Information