Introduction: Austrian Syndrome is a rare, life-threatening triad of pneumonia, meningitis, and endocarditis caused by Streptococcus pneumoniae, typically in immunocompromised or alcoholic patients. Though it accounts for ~14% of S. pneumoniae endocarditis cases, purulent pericarditis is exceptionally rare. We present a case complicated by purulent pericarditis with tamponade, highlighting the need for early recognition and multidisciplinary care. Case Description: A 63-year-old unhoused woman with tobacco and fentanyl use was found unresponsive by her son and brought to the emergency department by EMS. She presented with acute hypoxic respiratory failure, altered mental status, and abdominal pain. Vitals: BP 172/96 mmHg, HR 132 bpm, and hypoxia on 3 L oxygen via nasal cannula. Exam showed Kussmaul respirations, jugular venous distention, and cool extremities. Labs showed leukocytosis, lactic acidosis, acute kidney injury, and elevated troponin suggesting demand ischemia. ECG demonstrated electrical alternans; chest CT revealed a moderate-to-large pericardial effusion. Point-of-care ultrasound confirmed tamponade with right ventricular diastolic and right atrial systolic collapse; pulsus paradoxus was 27 mmHg. Emergent pericardiocentesis drained 465 mL of turbid fluid; cultures of pericardial fluid and blood grew S. pneumoniae, confirming purulent pericarditis. Transthoracic echocardiogram showed fibrinous strands along the right ventricular septum, suggesting endocarditis. Bronchoscopy confirmed pneumonia, completing Austrian Syndrome. Follow-up chest CT showed loculated pericardial fluid with mediastinal abscess, requiring urgent surgical washout, window creation, and drain placement. Despite intensive antibiotics and multidisciplinary care, she developed septic shock, respiratory failure requiring intubation, and renal failure managed with CRRT, the patient died from multiorgan failure. Discussion: Purulent pneumococcal pericarditis with tamponade is a rare, often fatal complication of Austrian Syndrome. Early recognition via bedside imaging and clinical signs like pulsus paradoxus and electrical alternans is critical. Due to the purulent loculated effusion, surgical washout, pericardial window, and mediastinal drains are typically required, as medical therapy alone is inadequate. Mortality remains high, particularly with shock and multiorgan failure. Rapid diagnosis and coordinated care are essential in invasive pneumococcal infections.

Austrian Syndrome: Are We Truly Aware of the Disease Progression?

49 Austrian syndrome in an immunocompromised patient

Introduction: Austrian syndrome is a triad of pneumonia, endocarditis, and meningitis due to S. pneumoniae . First characterized by Robert Austrian in 1956, it is a rare condition with an unknown incidence since the advent of the antibiotic age and introduction of the pneumococcal vaccine. Case Presentation: A 69-year-old female with a history significant for alcohol abuse presented with shortness of breath, productive cough and encephalopathy. The patient was septic with concurrent NSTEMI. She was emergently intubated for hypoxia and CT chest revealed multifocal pneumonia with a pericardial effusion. Echocardiogram (TTE) demonstrated a mitral annular calcification extending into the ventricle and confirmed a small fibrinous effusion without tamponade physiology. Infectious workup revealed S. pneumoniae bacteremia and pneumonia and he was initiated on ceftriaxone. The patient remained encephalopathic despite antibiotic treatment. Lumbar puncture revealed S. pneumoniae meningitis. The patient’s mentation continued to decline. MRI brain revealed an embolic shower. Repeat echocardiogram showed worsening pericardial effusion and the patient suffered a cardiac arrest due to pericardial tamponade resolved with emergent pericardiocentesis. Pericardial fluid was noted to be serofibrinous with predominance of leukocytes albeit culture negative. Unfortunately the patient succumbed to her illness and passed. Conclusions: Males, alcoholics, the immunocompromised, or those with a history of heart valve surgery are at risk for Austrian Syndrome. Mortality is as high as 60%-75%. This patient was at risk due to her history of alcoholism. Her presentation is unique in that she had concurrent purulent pericarditis, which is rarely attributed to S. pneumoniae. The condition is fatal if untreated and mortality ranges from 15%-40%. Treatment entails prompt drainage and appropriate antibiotic coverage. The advent of pneumococcal vaccination has significantly reduced the incidence of S. pneumoniae infection. This case represents the widespread effects of this organism if left unrecognized and untreated. Clinicians should have a high index of suspicion in any patient with pneumococcal infection and underlying predisposing factors.

Austrian syndrome is a rare and fatal triad of pneumonia, meningitis and endocarditis caused by Streptococcus pneumoniae, with a mortality rate of 60%. We report a case of Austrian syndrome in a 59-year-old patient, with a history of arterial hypertension on angiotensin 2 receptor antagonist therapy for five years, chronic smoking at 20 packs per year and occasional enolism for fifteen years, presenting with prolonged fever associated with loss of consciousness with no respiratory or cardiac signs, in whom purulent bacterial meningitis with positive Gram stain, infective endocarditis with mitral and aortic localization and interstitial pneumopathy have been demonstrated with negative blood cultures. Although the mortality rate is very high, early management of Austrian syndrome can improve the patient's quality of life.

Austrian syndrome corresponds to the triad of meningitis, pneumonia, and endocarditis caused by Streptococcus pneumoniae, there is no global or local incidence given the infrequency of entity. Scarce cases are published in Latin America, with none of them in Colombia. A case of Austrian syndrome by penicillin-resistant S. pneumoniae in an immunocompetent patient is presented. Aortic valve is the most frequent site involved in Austrian syndrome; this patient had an unusual localization of the vegetation on the right coronary artery ostium. The prognosis is poor with a mortality rate of 30% or higher, this patient survived despite systemic complications. Vaccination status impacts in prevention and severity of cases because responsible serotypes are often included in available vaccines. The patient had a serotype covered by available vaccines; however, her vaccination status was unknown. Thus, we present the first case reported in Colombia of Austrian syndrome by a penicillin-resistant S. pneumoniae, in a patient with no identified comorbidities or toxicological history, with a successful evolution.

Key Clinical MessageAustrian Syndrome classically consists of meningitis, endocarditis, and pneumonia due to Streptococcus pneumonia bacteremia. A literature review, however, does not show variants of this triad. Our case highlights a unique variant of Austrian Syndrome with mastoiditis, meningitis, and endocarditis which requires immediate recognition and treatment to prevent devastating patient outcomes.AbstractStreptococcus pneumonia is responsible for more than 50% of all bacterial meningitis and has a case fatality rate of 22% in adults. In addition, Streptococcus pneumonia is also one of the most common causes of acute otitis media, a known cause of mastoiditis. However, in conjunction with bacteremia and endocarditis, limited evidence is able to be identified. This sequence of infections also closely relates to Austrian syndrome. Otherwise known as Osler's triad, Austrian syndrome is a rare phenomenon of meningitis, endocarditis, and pneumonia secondary to Streptococcus pneumonia bacteremia that was first delineated by Robert Austrian in 1956. The incidence of Austrian syndrome is reported to be less than <0.0001% per year and has decreased significantly since the initial usage of penicillin in 1941. Despite this, the mortality rate of Austrian syndrome is still around 32%. Despite an extensive literature review, we were unable to find any reported cases of variants of Austrian syndrome that include mastoiditis as the primary insult. As such, we present a unique presentation of Austrian syndrome with mastoiditis, endocarditis, and meningitis with complex medical management that led to resolution for the patient. To discuss the presentation, progression, and complex medical management of a previously undiscussed triad of mastoiditis, meningitis, and endocarditis occurring in a patient.

AUSTRIAN SYNDROME IN A VACCINATED PATIENT: THE RARE STREPTOCOCCAL PNEUMONIAE TRIAD

Invasive Pneumococcal Disease Associated with Austrian Syndrome

Austrian syndrome associated with mitral paravalvular pneumococcal abscess.

Austrian Syndrome is the rare combination of a triad of endocarditis, meningitis, and pneumonia in the context of pneumococcal infection. Due to the involvement of several anatomical sites, the Austrian syndrome has a high mortality. Importantly, endocarditis is usually not considered during pneumococcal infection. We present a case of Austrian syndrome in a previously healthy 67-year-old woman. She featured with mental state alteration, respiratory failure, and shock, and was diagnosed with ceftriaxone-sensitive pneumococcal bacteremia, meningitis, and pneumonia. A transesophageal echocardiogram revealed vegetation of the mitral valve. Despite an improvement in her medical condition, she remained in a coma and died due to neurological complications. Even though the major cause of mortality in Austrian syndrome is cardiac involvement, meningitis is also linked with high morbidity and eventually death. We emphasize the relevance of an early diagnosis of the triad in order to decrease the very high mortality associated with this syndrome.

Pericardial variant of Austrian syndrome

SOLO SMARTステントレス生体弁が有効であったAustrian syndromeの再手術の1例

AUSTRIAN SYNDROME, THE UNLUCKY TRIAD: A CASE OF STREP PNEUMONIAE ENDOCARDITIS, MENINGITIS, AND PNEUMONIA

Introduction: Infectious endocarditis caused by Streptococcus pneumonia remains rare but serious. When it is associated with meningitis and pneumonia, it is called Austrian syndrome. Case Report: The authors describe a case of a 66-year-old female Moroccan patient who presented a congestive heart failure due to mitral valve disease after few days of hospitalization for pneumococcal meningitis associated with pneumonitis. The patient had a favorable course after combination of antibiotic therapy followed by surgical valve replacement. Conclusion: The recognition of this syndrome allows an early diagnosis of cardiac involvement often masked and which worsens the prognosis. Mortality can be lowered by appropriate medico-surgical management.

The clinical manifestations of Streptococcus pneumoniae disease(SPD) are various, and some patients with rare SPD types have a worse prognosis.Among them, the mortality is up to 70% after 48-72 hours of the onset of Streptococcus pneumoniae (SP)-related overwhelming post-splenectomy infection(OPSI). Purpura fulminans of SP(SP-PF) is often characterized by extensive purpura, fever, hypotension and disseminated intravascular coagulation, and prognosis of the patients without prodromal symptoms is poor.Infectious endocarditis has a mortality rate of 20.7% in SP-related cardiovascular diseases, and Austrian syndrome has a fatality rate of 43.5%.The mortality rate of bacterial pericarditis was 13.56%.At present, SP vaccine can not completely cover the 7 serotypes reported.Vasculitis mainly occurs in the thoracic and abdominal aorta and its branches, middle cerebral artery and so on.Of the 8 cases of hemophagocytic syndrome, 2 cases died.Early anti-infection, methylprednisolone shock and surgical treatment can improve the prognosis.Vaccination and drug prophylaxis can help those with under-lying diseases such as splenic dysfunction to reduce the incidence of SPD, such as SP-OPSI. Key words: Streptococcus pneumoniae disease; Overwhelming post-splenectomy infection; Purpura fulminans; Austrian′s syndrome

Acquired causes of Fanconi syndrome in adults are usually due to drugs, toxins or paraproteinaemias. Infectious causes are rarely described. We report a case of invasive pneumococcal disease in a patient who developed a Fanconi-like syndrome during the course of her illness. This patient presented with multiple electrolyte derangements consisting predominantly of hypokalaemia, hypomagnesaemia and hypophosphataemia during hospitalization for invasive pneumococcal disease with possible Austrian syndrome. Further evaluation revealed significant urinary losses of these electrolytes, uric acid and β2-microglobulin. Together with evidence of hypouricaemia, this is suggestive of proximal renal tubulopathy, and hence a Fanconi-like syndrome. The patient’s clinical condition and biochemical anomalies improved following pneumococcus treatment.LEARNING POINTSSuspect Fanconi syndrome when there are multiple electrolyte derangements consisting of hypokalaemia, hypomagnesaemia and hypophosphataemia.Recognise the common causes of Fanconi syndrome and appreciate that infections such as legionellosis, leptospirosis and pneumococcal disease can potentially result in Fanconi syndrome.The management of Fanconi syndrome is generally supportive and involves treating the underlying cause.

Large Tricuspid Valve Vegetation Secondary to Austrian Syndrome in a Healthy Young Adult

BackgroundAustrian syndrome, which is also known as Osler’s triad, is a rare aggressive pathology consisting of pneumonia, endocarditis, and meningitis caused by Streptococcus pneumoniae and carries drastic complications.Case presentationA case of a 68-year-old female with a past medical history of hypertension and had a recent viral influenza is presented. She developed bacterial pneumonia, endocarditis with mitral and aortic vegetations and perforation, meningitis, and right sternoclavicular septic arthritis. Two prior case reports have described sternoclavicular septic arthritis as part of Austrian syndrome. Our case is the third case; however, it is the first case to have this tetrad in an immunocompetent patient with no risk factors, i.e., males, chronic alcoholism, immunosuppression, and splenectomy.ConclusionsClinicians should maintain a high index of suspicion for the possibility of sternoclavicular joint septic arthritis as a complication of Austrian syndrome in immunocompetent patients.

Late-Onset Austrian Syndrome in a Patient with Bacterial Meningitis Late-Onset Austrian Syndrome in a Patient with Bacterial Meningitis (P5.9-006)