Critical Care: Student/Resident Case Report Poster - Critical Care IV |

An Infectious Cascade: A Rare Case of Austrian Syndrome in an Alcoholic Presenting With Sepsis FREE TO VIEW

Scott Ferrara, DO; Scott Kopec, MD; Michael Newstein, MD
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University of Massachusetts Internal Medicine Residency Program, Worcester, MA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):444A. doi:10.1016/j.chest.2016.08.457
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care IV

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Severe sepsis and septic shock are common problems in the ICU. Early initiation of antibiotics is the standard of care, followed by source identification and control. Patients unresponsive to this approach warrant more extensive work-up. To emphasize this we present a case of concurrent Streptococcus pneumoniae pneumonia, meningitis, and endocarditis, also called Austrian Syndrome.

CASE PRESENTATION: A 57 year old female with alcohol abuse presented with altered mental status. She was tachycardic, hypotensive, tachypneic, and febrile. Initial labs showed a leukocytosis and lactic acidosis. Due to persistent hypotension after fluid resuscitation, norepinephrine was started. A noncontrast head CT was negative. The patient rapidly deteriorated into hypoxic respiratory failure requiring intubation. A portable chest x-ray showed a dense consolidation occupying most of the right lung. Blood, sputum, and urine cultures were obtained. The patient was started on vancomycin, ceftriaxone, and ampicillin for severe community acquired pneumonia and concern for meningitis. A lumbar puncture was performed, cerebrospinal fluid labs showed a WBC of 1943 (70% neutrophils), glucose 14, protein 224, and gram + cocci in chains, confirming bacterial meningitis. Gram stains from blood and sputum resulted as gram + cocci in chains and cultures confirmed pan-sensitive S. pneumoniae. Antibiotics were de-escalated to ceftriaxone. After 7 days of antibiotics, all the patient's parameters and labs improved except for poor mental status. A brain MRI showed multiple areas of acute infarction suspicious for septic embolic. A transesophageal echocardiogram revealed filamentous structures on the mitral valve, confirming bacterial endocarditis. Gradually the patient’s mental status improved. She was discharged to a rehabilitation center to complete 4 weeks of ceftriaxone.

DISCUSSION: The syndrome of concurrent S. pneumoniae pneumonia, meningitis, and endocarditis was first described by Robert Austrian in 1956 and is known as Austrian Syndrome. There is a correlation with this syndrome and alcoholism. Hypotheses for this correlation include: splenic dysfunction, defective leukocyte response and poor chemotaxis. The most common cardiac location is the aortic valve. The recognition of Austrian Syndrome is often missed due to an overlap of clinical symptoms in septic patients and the delay of infection manifesting in all three systems.

CONCLUSIONS: A patient with severe sepsis or septic shock not responding appropriately to therapy should alert clinicians for other sources of infection.

Reference #1: Kanakadandi V et al.The Austrian Syndrome: A case report and review of the literature.Infection2013;41:695-700

Reference #2: Buchbinder N et al.Alcoholism:An Important but Unemphasized Factor Predisposing to Bacterial Endocarditis.Archives of Internal Medicine1973;132:689-692

Reference #3: Aronin S et al.Review of Pneumococcal Endocarditis in Adults in the Penicillin Era.Clinical Infectious Diseases1998;26-165-171

DISCLOSURE: The following authors have nothing to disclose: Scott Ferrara, Scott Kopec, Michael Newstein

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