INTRODUCTION: Disseminated pneumococcal infection is uncommon in the antibiotics era. We are reporting a case of Austrian Syndrome which is characterized by Osler's triad of pneumonitis, meningitis and infective endocarditis caused by invasive pneumococcal infection. So far less than 50 cases have been reported.
CASE PRESENTATION: 73 years old African American female was brought to the ED by her family for unresponsiveness. The patient was in her usual state of health until 2 weeks ago. She started to have back pain after lifting some heavy objects. 2 days prior to admission she started to feel bilateral lower extremity weakness. One day prior to admission she started to have upper extremity weakness she went to a neurologist who recommended an MRI for the patient. Same night she had dyspnea and was brought to the ED. Past medical and surgical history was unremarkable and no history of tobacco, alcohol or illicit drug use was reported. She was afebrile with HR of 110–140 and BP of 95/55. Her pulse oximetry showed SpO2 of 94% on 4L O2. She was in respiratory distress and endotracheal intubation was done in ED. She was sedated. She had few crackles on left lower lobe and lower extremity weakness. Rest of the physical examination was normal. Chest x-ray revealed left lower lobe pneumonia. Laboratory examination showed leucocytosis, positive blood culture for S. Pneumonae. CSF analysis was compatible with bacterial meningitis. 2D and trans-esophageal echocardiography (TEE) showed large sessile vegetation (1.1×1.4 cm) on anterior mitral valve leaflet with aneurysm and two perforations of cusp and severe valvular regurgitation. Diagnosis of Austrian Syndrome was considered for Osler's triad. Broad spectrum antibiotics were started from beginning. Unfortunately she developed large embolic stroke and her neurological status was worsened. Family requested to withdraw support and she died. Autopsy report was consistent with triad of meningitis, pneumonitis and infective endocarditis.
DISCUSSIONS: Discussion:Osler's triad is triad of meningitis, pneumonia and endocarditis was first described in 1881 by Osler and it was causally linked with Streptococcus pneumoniae in 1957 by Robert Austrian. Most of this disease is seen in alcoholics and immuno-compromised patients. The usual portal of entry for Osler's triad is the lung, followed by cardiac valve or meninges. Despite adequate antibiotics, the evolution is usually acute and very aggressive, with a high rate of local (perforated perivalvular abscesses) and systemic complications, requiring surgical treatment in most cases. Three clinical features make our case unique. 1. Patient did not have any risk factor (no alcoholism) 2. She had native mitral valve involvement. 3. Involvement of mitral valve was very severe suggestive of very aggressive nature of disease. She had symptom of back ache for almost 2weeks. If she had presented earlier her disease state might be reversible without any long term sequel.
CONCLUSION: Invasive pneumococcal infection can happen in this advance antibiotics era without any predisposing conditions. Outcome of the infection may be fatal. Early recognition and prompt treatment can save life.
DISCLOSURE: Bhavinkumar Dalal, No Financial Disclosure Information; No Product/Research Disclosure Information