A 36-year-old man with advanced HIV and probable multivalvular pneumococcal endocarditis was managed with empiric therapy based on noninvasive data after declining transesophageal echocardiography.
Case Report (n=1)
Multivalvular pneumococcal infective endocarditis can be pragmatically managed with empiric therapy based on noninvasive signals when patients decline invasive confirmatory testing like transesophageal echocardiography.
Abstract Introduction Pneumococcal endocarditis has become rare in the modern era, and the classic Austrian triad (pneumonia, endocarditis, meningitis) is infrequently encountered. Diagnostic certainty can be challenged when invasive testing is declined, forcing clinicians to synthesize noninvasive data, patient preferences, and risk-benefit tradeoffs into a pragmatic plan. Case A 36-year-old man with intravenous drug use presented with two weeks of dyspnea, productive cough, diarrhea, and pleuritic chest pain. On arrival, hemoglobin was 5.1 g/dL, C-reactive protein 17.2 mg/dL, and chest imaging showed diffuse bilateral infiltrates. He progressed from nasal cannula to BiPAP and required endotracheal intubation within 24 hours. Blood cultures on hospital day 1 grew Streptococcus pneumoniae (2/2). Transthoracic echocardiography demonstrated reduced left-ventricular ejection fraction, left-atrial dilation, mitral regurgitation, a small pericardial effusion, and mobile echodensities on the aortic valve and on the anterior leaflet of the tricuspid valve concerning for infective endocarditis (IE). Concurrently, bronchoscopy removed copious secretions; Pneumocystis jirovecii PCR from lower respiratory samples was positive. High-dose trimethoprim-sulfamethoxazole with corticosteroids was initiated for PJP; ceftriaxone was escalated for invasive pneumococcal disease with suspected meningitis. The patient declined transesophageal echocardiography (TEE) and lumbar puncture after multidisciplinary counseling (ICU, infectious diseases, cardiology) about procedural risk, re-intubation possibility, and alternatives. Rapid-start antiretroviral therapy (dolutegravir plus tenofovir disoproxil fumarate/emtricitabine) was begun in the ICU. He improved clinically, was extubated by hospital day 8, and transitioned to room air. Given the high pretest probability for IE (pneumococcal bacteremia, IVDU, multivalvular mobile echodensities), ceftriaxone was continued for a prolonged, IE-directed course, with plans for close outpatient follow-up and repeat echocardiography; ultimately, he left against medical advice. Discussion/Novelty This case represents a near-Austrian syndrome, pneumonia with probable multivalvular pneumococcal IE and empiric meningitis coverage, managed without invasive confirmation. It highlights a structured approach when gold-standard tests are declined: (1) quantify pretest probability using clinical context, microbiology, and TTE morphology; (2) treat the most morbid plausible diagnosis (IE) when risk is acceptable; (3) operationalize patient-centered harm-reduction. The coexistence of PJP further complicates presentation and emphasizes vigilance for dual etiologies in advanced HIV. Conclusion When patients decline TEE/LP, clinicians can deliver pragmatic, patient-centered care by integrating robust noninvasive signals to justify IE-directed therapy, while arranging tight follow-up and support. This case underscores that multivalvular pneumococcal IE, though uncommon, should remain high on the differential in severe pneumonia with bacteremia, especially in advanced HIV and IVDU and can be ethically and effectively managed without invasive confirmation. This abstract is funded by: None
Quasem et al. (Fri,) conducted a case report in Near-Austrian Syndrome in Advanced HIV (n=1). Empiric endocarditis-directed therapy (ceftriaxone) and PJP treatment was evaluated. A 36-year-old man with advanced HIV and probable multivalvular pneumococcal endocarditis was managed with empiric therapy based on noninvasive data after declining transesophageal echocardiography.