Introduction: Austrian Syndrome is a rare triad of pneumonia, meningitis, and infective endocarditis caused by S. pneumoniae. Despite appropriate treatment, it carries a mortality of more than 28%, making early diagnosis and intervention critical. We present an atypical case involving the mitral valve in a patient without classic risk factors such as immunosuppression or alcohol use
Description: A 73-year-old woman with hypertension and breast cancer in remission presented with four days of dry cough, myalgias, and subjective fevers, progressing to somnolence and confusion. On exam, she was febrile, tachycardic, and tachypneic, with neck stiffness and positive Kernig and Brudzinski signs. Initial labs showed leukocytosis with neutrophilic predominance, elevated creatinine, and mild transaminitis. Chest X-ray revealed a patchy left lower lobe opacity. Empiric treatment with ceftriaxone, vancomycin, ampicillin, and acyclovir was given for severe sepsis with suspected meningitis. Her course was complicated by new-onset atrial fibrillation and respiratory failure requiring intubation. Blood and sputum cultures grew S. pneumoniae, and CSF yielded gram-positive cocci. Transthoracic echocardiography revealed a moderate vegetation on the posterior mitral leaflet with moderate-severe regurgitation confirmed by TEE. Antibiotics were narrowed to IV penicillin and mental status steadily improved. Repeat cultures were negative, and she was extubated by hospital day 10. On day 16, she underwent mitral valve replacement with a bovine bioprosthesis and completed a six-week course of IV penicillin
Discussion: Austrian Syndrome remains exceedingly rare in the modern antibiotic era, with only a few hundred cases reported and mitral valve involvement occurring in just 24% of patients. This case is especially unusual, as the patient lacked common risk factors such as male sex, middle age, immunosuppression, or alcohol abuse. Due to its high mortality, clinicians should maintain a strong index of suspicion in any patient presenting with altered mentation, a new or changing murmur, and S. pneumoniae bacteremia, regardless of typical risk factors. Early diagnosis, prompt imaging, timely empiric antibiotics, and consideration of surgical intervention are critical to improving outcomes in these rare but life-threatening cases
