The triad of pneumonia, meningitis and infective endocarditis (IE) due to pneumococcus was first described in 1862. We present what we believe to be the first reported case of Austrian syndrome with four-valve involvement.
A 54-year-old male presented with a two-week history of fever, cough and headache. He had no medical history and denied intravenous (IV) drug abuse. Examination revealed an early diastolic murmur with basal crackles in the left lung. Chest radiograph showed bronchopneumonia. He was started on IV antibiotics. Blood cultures were non-yielding. Vegetations involving the mitral and aortic valves were seen on transthoracic echocardiography. On the fourth hospitalization day, he developed right arm weakness and seizures. Magnetic resonance imaging revealed leptomeningeal enhancement, and cortical infarcts. A spinal tap performed was consistent with meningitis but gram stain and culture were negative. Cerebrospinal fluid S. pneumoniae antigen was positive. A diagnosis of Austrian syndrome with septic brain emboli was made. Transesophageal echocardiography showed a ventricular septal defect and quadruple-valve IE, complicated by aortic valvular perforation and regurgitation. He developed multi-organ failure before surgery and passed away. A PubMed search for English reports of quadruple valve IE was conducted for the literature review.
A total of 19 cases were available, including our patient. The mean age of presentation was 48.3 years, ranging from 7 to 82 years. There were more men (84.2%) than women (15.8%). Four patients had a history of IV drug abuse, four had underlying congenital heart disease and one had both. Two patients (10.5%) had two pathogens isolated. S. aureus and S. viridans (three cases, 15.8% each) were most commonly implicated. Heart failure was the commonest complication, seen in eight patients (42.1%). The case fatality rate was 52.6%. Cardiac surgery was of borderline significance in predicting survival (p = 0.054). IE was diagnosed only at post-mortem in two cases (10.5%).
We report a case of quadruple valve IE due to S. pneumoniae, presenting with Austrian triad in a patient with a newly diagnosed ventricular septal defect. Risk factors for quadruple valve IE include congenital heart disease and IV drug abuse. Clinicians need to remain vigilant in the presence of these risk factors.
H. Shafi, None
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