Pneumococcal Mitral Endocarditis Unmasking Austrian Syndrome

BACKGROUND: Austrian syndrome is the rare triad of pneumococcal pneumonia, endocarditis, and meningitis and represents a fulminant form of invasive Streptococcus pneumoniae infection with a reported mortality of 20%-40%. CASE SUMMARY: A 57-year-old woman with untreated hepatitis C, chronic injection drug use, and heavy tobacco exposure presented with encephalopathy and acute hypoxemic respiratory failure requiring intubation. Bilateral infiltrates were seen on chest imaging. All 4 blood culture samples were positive for Streptococcus pneumoniae, and transthoracic echocardiography demonstrated a large (>1.5 cm), mobile, destructive mitral valve vegetation. Computed tomography revealed deep neck, shoulder, and gluteal abscesses with airway edema. Lumbar puncture on hospital day 6 confirmed pneumococcal meningitis, completing Austrian syndrome. The patient died during the index hospitalization. DISCUSSION: Pneumococcal bacteremia with encephalopathy should prompt early transthoracic echocardiography and cerebrospinal fluid evaluation to identify Austrian syndrome and guide antimicrobial and source control decisions.