The missing link in Austrian syndrome

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M.H.E. Vossen, L. Dawson

Voorzitter(s): prof. dr. R.P. Koopmans, MUMC, Maastricht & dr. C.J.A.M. Konings, Catharina Ziekenhuis, Eindhoven

Woensdag 22 april 2015

15:00 - 16:00u in Zaal 2.1

Categorieën: parallelsessie (case reports/research)

Parallel sessie: Parallelsessie 5: Case reports/research

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Introduction:
Streptococcus pneumoniae infection with pneumonia, meningitis and endocarditis is known as Osler’s triad or the Austrian syndrome.

Case description:
A 41-year old female, known with insuline dependent diabetes mellitus and multiple sclerosis, treated with insulin, Interferon B, losartan and pravastatin, presented with flu-like symptoms and fever. On physical examination the airway was free, respiratory rate 50/min, saturation 90% with peripheral cyanosis while breathing oxygen in a non-rebreather mask. Pulmonary examination revealed audible rales located in the right upper lobe. Blood pressure was 160/85 mmHg, pulse 130/min, temperature 40° Celsius. She was comatous (E2M4V1) with an ophisthotonus and immediately intubated.On suspicion of pneumonia and meningitis blood cultures and lumbar puncture were performed and ceftriaxone was started. Both cultures were positive for Streptococcus pneumoniae, therefore the antibiotic was switched to penicillin. However, fever relapsed and a heart murmur was heard. A transesophageal echocardiography showed large mitral and pulmonal valve vegetations with a severe mitral valve insufficiency. An urgent valve replacement was performed; the patient recovered fully.

Discussion:
The incidence of Streptococcus pneumoniae endocarditis has decreased from 10-15% to 1-3% over the last years. Therefore, the Austrian syndrome is rarely seen. Risk factors are impaired systemic host responses such as diabetes or conditions affecting local clearance mechanisms. The mortality of patients with Austrian syndrome when solely treated with antibiotics is 63-80%. Treatment with a combination of antibiotics and valve replacement has decreased mortality to 32%. We recommend in patients with a combination of Streptococcus pneumoniae pneumonia and meningitis screening for endocarditis.