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Austrian's Triad Complicated by Suppurative International Journal of Infectious Diseases (2009) 13, e23—e25 http://intl.elsevierhealth.com/journals/ijid CASE REPORT Austrian’s triad complicated by suppurative pericarditis and cardiac tamponade: a case report and review of the literature Jose P. Vindas-Cordero, Michael Sands *, Wilfredo Sanchez Department of Medicine, Infectious Diseases Division, 1833 Boulevard, Suite 500, University of Florida, Jacksonville, Florida 32206, USA Received 1 February 2008; received in revised form 16 April 2008; accepted 17 April 2008 Corresponding Editor: Craig Lee, Ottawa, Canada KEYWORDS Summary Austrian’s triad is a rare complication of disseminated Streptococcus pneumoniae Streptococcus infection consisting of pneumonia, meningitis, and endocarditis. We report what we believe to be pneumoniae; the first case of Austrian’s triad further complicated by purulent pericarditis and cardiac Austrian’s syndrome; tamponade, and review the relevant literature. Suppurative pericarditis; Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. Cardiac tamponade; Bacterial endocarditis Introduction chest X-ray showed the presence of cardiomegaly (Figure 1). A computed tomography scan of the chest showed a large Austrian’s triad, a rare complication of disseminated Strepto- pericardial effusion with signs of cardiac tamponade, a right coccus pneumoniae infection consisting of pneumonia, menin- lower lobe infiltrate, and a small right pleural effusion gitis, and endocarditis, is a clinical reminder of the virulent (Figure 2). The pericardial effusion was confirmed by echo- potential of S. pneumoniae. We describe what we believe to be cardiography and an emergent pericardiocentesis was per- the first reported case of Austrian’s triad further complicated formed, yielding 300 ml of purulent fluid. She was taken to with pericarditis and cardiac tamponade. the operating room and a pericardial window placed with the drainage of an additional 400 ml of purulent fluid. The pericardium was noted to be thickened with a fibrinopurulent Case report exudate present (Figure 3). A pericardial biopsy showed fibrinovascular tissue with chronic inflammation, fibrous A 49-year-old, obese, alcoholic, HIV-negative African-Amer- adhesions, and fibrinopurulent exudate. Following surgery, ican woman was evaluated in the emergency department the patient remained hemodynamically stable with only a with complaints of worsening shortness of breath and fever brief episode of mild renal insufficiency with peak creatinines for several days. She was felt to be in cardiac tamponade. A of 2.2. Repeat transthoracic and transesophageal echocar- diograms showed resolution of the pericardial effusions and * Corresponding author.Tel.: +1 904 253 1326; fax: +1 904 798 2784. the presence of a 1 Â 1.5 cm pedunculated vegetation on the E-mail address: [email protected].fl.us (M. Sands). anterior mitral valve leaflet. 1201-9712/$36.00. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. doi:10.1016/j.ijid.2008.04.005 e24 J.P. Vindas-Cordero et al. Figure 3 Intra-operative view of the exposed pericardium. her antibiotic therapy. A follow-up echocardiogram 8 months later showed an ejection fraction of 55% and mild nonspecific Figure 1 Admission chest X-ray. thickening of the anterior mitral valve leaflet with minimal mitral regurgitation. She was living at home, fully ambula- Blood, pericardial fluid, and pericardial biopsy cultures tory, and had resumed her usual activities. were all negative. Gram stain of the pericardial fluid demon- strated many neutrophils, but no organisms. Discussion It was recognized that the patient had been discharged from the hospital 7 days previously. During the previous hos- Pneumococcal disease remains a significant cause of morbid- pitalization she had S. pneumoniae meningitis, bacteremia, ity and mortality, however endocarditis and pericarditis have pneumonia, and left shoulder septic arthritis. Cultures of become rare complications of bacteremic pneumococcal cerebrospinal fluid and blood had grown S. pneumoniae fully disease. In Mufson and Stanek’s landmark 20-year longitudi- sensitive to penicillin, with a minimum inhibitory concentra- nal study of bacteremic pneumococcal pneumonia in a well- tion of <0.1 mg/ml. She had received 14 days of intravenous defined community, it was noted that the incidence rate in ceftriaxone and closed left shoulder joint drainage and was patients over 50 years of age had increased over time. The discharged home ambulatory receiving oral amoxicillin. overall case—fatality rate during the 20-year period, how- Based on the prior hospitalization’s culture results, the ever, declined from the initial 38.5% to 28.6% in the last 5- patient was treated for S. pneumoniae endocarditis and year interval of 1993—1997, possibly due to the combined use pericarditis with a 4-week course of ceftriaxone 2 g every of a beta-lactam and macrolide antibiotics.1 No associated 12 hours plus vancomycin to maintain a trough of 15—20 mg/ cases of endocarditis or pericarditis were reported in that ml, and an initial 2 weeks of intravenous gentamicin 1 mg/kg study. In a prospective, multicenter, international, observa- every 8 hours. She did clinically well and after the first 2 tional study of hospitalized patients with S. pneumoniae weeks was transferred to a rehabilitation facility to complete bacteremia, only five of 844 (0.6%) patients developed endo- carditis and three of 844 (0.36%) developed pericarditis.2 Pneumococcal pericarditis has been rarely reported since the advent of effective antimicrobial therapy. In 1964 Aus- trian and Gold published a review of 529 cases of pneumo- coccal bacteremia with no identified cases of pericarditis.3 A 30-year literature review of pneumococcal endocarditis in the penicillin era by Aronin et al., covering the period 1966— 1996, identified a total of 197 adult cases. No cases of concomitant clinical pericarditis were noted, although four of 38 (10.5%) patients undergoing echocardiography had pericardial effusions.4 Taylor and Sanders reviewed the clin- ical spectrum of 2064 reported cases of non-meningitic invasive pneumococcal disease encompassing 30 years of published literature (1966—1997). They identified 70 isolated cases of pericarditis and five of cardiac tamponade.5 In the period 1980—1998 only 15 cases of pneumococcal pericarditis were reported in the literature.6 The concurrence of bacteremic pneumococcal pneumonia, meningitis, and endocarditis is a rare and virulent presentation of invasive pneumococcal disease, first described by Osler and Figure 2 Admission computed tomography of the chest. later described and published by Austrian, for whom the Austrian’s triad with complications e25 syndrome is named.7 Austrian’s syndrome remains rarely References reported in the literature. Aronin et al. mentioned that 116 or 59% of the 197 reviewed cases of pneumococcal endocarditis 1. Mufson MA, Stanek RJ. Bacteremic pneumococcal pneumonia in had concurrent meningitis and that 29 of those had Osler’s one American city: a 20-year longitudinal study, 1978—1997. Am J 4 triad. A recent report and review by Gonzalez-Juanatey et al. Med 1999;107(1A):S34—43. identified two cases of Austrian’s syndrome over a 15-year 2. Kan B, Ries J, Normark BH, Chang FY, Feldman C, Ko WC, et al. period at their institution in Lugo, Spain and reviewed an Endocarditis and pericarditis complicating pneumococcal bacter- additional 16 well-defined cases from the literature.8 No cases aemia, with special reference to the adhesive abilities of pneu- of associated pericarditis or cardiac tamponade were identi- mococci: results from a prospective study. Clin Microbiol Infect fied. Their review reconfirmed that alcoholism or hepatic 2006;12:338—44. 3. Austrian R, Gold J. Pneumococcal bacteremia with especial cirrhosis was a significant risk factor for invasive pneumococcal reference to bacteremic pneumococcal pneumonia. Ann Intern disease, occurring in eight of 16 patients. HIV was identified in Med 1964;60:759—76. one of 16 patients. The aortic valve was involved in 12 of 16 4. Aronin SI, Mukherjee SK, West JC, Cooney IL. Review of pneumo- (75%) patients and valve replacement required in eight of the coccal endocarditis in adults in the penicillin era. Clin Infect Dis 12 patients. Munoz et al. reported a case of Austrian’s syn- 1998;26:165—71. drome caused by a highly penicillin-resistant S. pneumoniae. 5. Taylor SN, Sanders CV. Unusual manifestations of invasive pneu- Purulent pericarditis was encountered during emergent mitral mococcal infection. Am J Med 1999;107(1A):S12—27. valve replacement.9 6. Go C, Asnis DS, Saltzman H. Pneumococcal pericarditis since 1980. We have described what we believe to be the first reported Clin Infect Dis 1998;27:1338—40. case of Austrian’s syndrome associated with pericarditis and 7. Austrian R. Pneumococcal endocarditis, meningitis and rupture of the aortic valve. Arch Intern Med 1957;99:539—44. cardiac tamponade. This report serves as a reminder of the 8. Gonzalez-Juanatey C, Testa A, Mayo J, Gonzalez-Gay MA. Austrian possibly severe clinical consequences of bacteremic pneumo- syndrome: report of two new cases and literature review. Int J coccal disease. Echocardiography should be considered early Cardiol 2006;108:273—5. in the course of illness for patients with concurrent bacteremic 9. Munoz P,Sainz J, Rodriguez-Creixems M, Santos J, Alcala L, Bouza pneumococcal pneumonia and meningitis. E. Austrian syndrome caused by highly penicillin resistant Strep- Conflict of interest: No conflict of interest to declare. tococcus pneumoniae. Clin Infect Dis 1999;29:1591—2..
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