Austrian Syndrome: report of one case and a systematic review of case reports - new insights

OBJECTIVE

The objective of this review was to gain new insight into the rare condition, Austrian syndrome: the triad of endocarditis, meningitis, and pneumonia caused by Streptococcus pneumoniae.

METHODS

A systematic review of case reports was conducted using the PRISMA guideline. Cases were rigorously screened to meet a set of well-defined inclusion criteria. Relevant data was aggregated and reported using descriptive statistics.

RESULTS

Seventy-one cases from 69 case reports were included in the final review. The mean age was 56.5 years with a male-to-female ratio of 2.4:1. Alcoholism was reported in 41% of patients. Altered mental state (69%) and fever (65%) (mean temperature on admission = 38.9°C) were the commonest presenting symptoms. The mean duration of symptoms before presentation to the hospital was 8 days. The aortic valve was most commonly affected (56%). The mean duration of antibiotic therapy was 5.6 weeks. Seventy percent of patients were admitted to the intensive care unit (ICU). Fifty-six percent of patients had valvular surgery. The average length of stay in the hospital was 36.9 days. Mortality was recorded in 28% of patients.

CONCLUSION

Austrian syndrome is rare but deadly. The true incidence is unknown but is commoner in middle-aged men and in alcoholics. Affected patients are usually critically unwell, often requiring ICU admission and prolonged hospital stays. Treatment is aggressive including prolonged courses of antibiotics and often, surgery. Despite these, the case fatality rate is high, with death occurring in over a quarter of patients. Surgery appears to be associated with better prognosis.

Triad of Terror: Rapidly Progressive Austrian Syndrome in a 62-Year-Old Female

We report a case of a 62-year-old female presenting with shortness of breath, who was subsequently diagnosed with Austrian syndrome. The patient had a complicated clinical course, including invasive central nervous system pneumococcal disease, pneumococcal bacteremia, and mitral valve vegetation with possible leaflet perforation. Despite aggressive treatment, her condition continued to worsen. We will discuss the clinical features of this disease, approaches to diagnosis and treatment, and outcomes in light of this rare condition.

AUSTRIAN SYNDROME: A RARE CASE REPORT

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.

Meningitis and endocarditis as a sequela of streptococcus pneumonia mastoiditis: A case report

Key Clinical Message

Austrian 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.

Abstract

Streptococcus 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.

Combined Bacterial Meningitis and Infective Endocarditis: When Should We Search for the Other When Either One is Diagnosed?

Introduction

We aimed to describe patients with coexisting infective endocarditis (IE) and bacterial meningitis (BM).

Methods

We merged two large prospective cohorts, an IE cohort and a BM cohort, with only cases of definite IE and community-acquired meningitis. We compared patients who had IE and BM concurrently to patients with IE only and BM only.

Results

Among the 1030 included patients, we identified 42 patients with IE–BM (4.1%). Baseline characteristics of patients with IE–BM were mostly similar to those of patients with IE, but meningitis was the predominant presentation at admission (39/42, 92.3%). Causative pathogens were predominantly Streptococcus pneumoniae (18/42, 42.9%) and Staphylococcus aureus (14/42, 33.3%). All pneumococcal IE were associated with BM (18/18). BM due to oral and group D streptococci, Streptococcus agalactiae, and S. aureus were frequently associated with IE (14/30, 46.7%). Three-month mortality was 28.6% in patients with IE–BM, 20.5% in patients with IE, and 16.6% in patients with BM.

Conclusions

Patients with pneumococcal IE or altered mental status during IE must be investigated for BM. Patients with S. aureus, oral and group D streptococcal or enterococcal BM, or unfavorable outcome in pneumococcal meningitis would benefit from an echocardiography. Patients with the dual infection have the worst prognosis. Their identification is mandatory to initiate appropriate treatment.

Austrian syndrome followed by severe cutaneous adverse reactions in a HIV patient

Invasive pneumococcal infection, defined as the combination of pneumonia with endocarditis and meningitis, was described as Austrian syndrome in the 1800s. We report the case of a 63-year-old woman with underlying human immunodeficiency virus who presented with fever and altered mental status. Subsequent workup supported a diagnosis of Austrian syndrome. During the 5-week course of ceftriaxone treatment, she developed fever, pruritus and follicular accentuation throughout the body. Labs were significant for eosinophilia, which along with systemic symptoms, supported the diagnosis of a drug reaction. Coagulase negative staphylococcus bacteremia was discovered when the patient developed septic shock. Subsequently, diffuse desquamative eruption with rapidly progressing sloughing appeared and biopsy proved toxic epidermal necrolysis. Patient eventually succumbed to multiorgan failure.

Quadruple valve infective endocarditis presenting with suspected Austrian syndrome: a case report and a case series of quadruple valve infective endocarditis

OBJECTIVES

Austrian syndrome comprises the triad of pneumonia, meningitis, and endocarditis secondary to Streptococcus pneumonia. We present what we believe to be the first reported case of Austrian syndrome with quadruple heart valve involvement and review the literature detailing cases of quadruple valve infective endocarditis.

CASE PRESENTATION AND RESULTS

A case is presented of a patient with radiographic evidence of a left lower lobe pneumonia. Sequential transthoracic followed by transesophageal echocardiogram done to evaluate the presence of a cardiac murmur revealed the presence of quadruple valve vegetations. Multiple blood cultures were persistently negative. The patient went on to develop seizures secondary to proven meningitis. Microbiological diagnosis was eventually established through positive Streptococcus pneumoniae antigen (Alere BinaxNOW®) from cerebrospinal fluid, establishing a presumptive clinical diagnosis of Austrian syndrome. A computerized PubMed search for reports of quadruple valve infective endocarditis and their references was collated. A total of 22 patients were found, including our patient. The median age of presentation was 47.5 years. Five patients had a history of intravenous drug abuse, another 5 had underlying congenital heart disease, and 1 had both. Two patients (9.1%) had 2 microorganisms isolated. Staphylococcus aureus and Streptococcus viridans (3 cases, 13.6% each) were the most commonly implicated microorganism. Heart failure was the commonest complication, afflicting 11 patients (50.0%). Ten patients (45.5%) underwent surgery. Overall case fatality rate was 50.0%. Cardiac surgery was of statistical significance in predicting survival (P = 0.009).

CONCLUSION

Quadruple valve endocarditis is associated with a high mortality rate, and cardiac surgery may be protective.

Severe Austrian Syndrome in an Immunocompromised Adult Patient - A Case Report

Background

Known also as Osler's triad, Austrian syndrome is a complex pathology which consists of pneumonia, meningitis and endocarditis, all caused by the haematogenous dissemination of Streptococcus pneumoniae. The multivalvular lesions are responsible for a severe and potential lethal outcome.

Case Report

The case of a 51-year-old female patient, with a past medical history of splenectomy, is presented. She developed bronchopneumonia, acute meningitis and infective endocarditis as a result of Streptococcus pneumoniae infection and subsequently developed multiple organ dysfunction syndromes which led to a fatal outcome. Bacteriological tests did not reveal the etiological agent. The histopathological examination showed a severe multivalvular endocarditis, while a PCR based molecular analysis from formalin fixed valvular tissue identified Streptococcus pneumoniae as the etiologic agent.

Conclusions

The presented case shows a rare syndrome with a high risk of morbidity and mortality. Following the broad-spectrum treatment and intensive therapeutic support, the patient made unfavourable progress which raised differential diagnosis problems. In this case, the post-mortem diagnosis demonstrated multiple valvular lesions occurred as a result of endocarditis.

Successful medical management of a case of Austrian syndrome-an uncommon entity in the modern antibiotic era: a case report

BACKGROUND

Austrian syndrome-the combination of meningitis, pneumonia and infective endocarditis due to Streptococcus pneumoniae infection, is a rare entity. In literature only a few hundreds of cases are reported but surprisingly we did not find any report on Austrian syndrome in or from Bangladesh.

CASE PRESENTATION

We report the case history of a middle aged Bangladeshi diabetic man, who had fever, cough, shortness of breath and altered mentation. He had tachycardia, bi-basal lung crepitations, new cardiac murmurs and meningism. Diagnostic work-up revealed Austrian syndrome. Because of the rarity of the condition, this case is reported.

CONCLUSION

A case of pneumococcal pneumonia or meningitis should raise suspicion of concomitant endocarditis and Austrian syndrome, specially if there is heart failure, as early recognition and treatment may appear life-saving.

Rapidly Progressive and Almost Lethal Pneumonia

We herein describe the case of a 65-year-old male patient who presented with Osler's triad, which is the combination of endocarditis, pneumonia, and meningitis. This report is even more unusual since the pathogen isolated was the invasive and virulent strain of Streptococcus pneumoniae serotype 3. The clinical entity described is also called Austrian syndrome. Even though rare in this antibiotic era, the syndrome remains one of high morbidity and mortality. This particular case is of paramount importance for the clinician reader. First, it documents the clinical features associated with invasive pneumococcal disease and the Austrian syndrome. Second, and equally important, it highlights why following the Surviving Sepsis Campaign guidelines saves lives. For this case, the following steps were taken: 1. As a surrogate for perfusion, early and aggressive fluid resuscitation therapy (guided by lactic acid levels) was instituted; 2. also early in the treatment, broad spectrum antibiotics were administered; 3. to guide antibiotic therapy, microbiological cultures were obtained. The patient subsequently improved and was transferred to the internal medicine ward to complete 4 weeks of antibiotic therapy.