Case Presentation: A 68-year-old female presented to the emergency department with altered mental status. A few weeks prior to presentation, she was found to have a viral influenza infection which was managed supportively. Approximately one week prior to presentation, she had started developing a productive cough associated with body aches and fatigue, and eventually developed confusion which brought her to the hospital. Her medical history was only notable for well controlled hypertension. She was immunocompetent without any history of intravenous drug use.
In the ED, she was found to have a low-grade fever of 100.8F, tachycardia (heart rate of 115), and tachypnea. Her blood pressure was stable. She also had general confusion and found to have left lower lobe crackles, a pan-systolic murmur which was louder at the apex, and weakness in the right-sided upper and lower extremities. Chest x-ray showed multi-focal infiltrates suggestive of pneumonia.
Brain magnetic resonance imaging was completed and demonstrated leptomeningeal enhancement suggestive of meningitis. Further cerebrospinal fluid analysis showed leukocytosis (WBC 2345/mm3, with 83% neutrophils), high protein, low glucose, and positive Streptococcus pneumoniae by polymerase chain reaction (PCR). Sputum and blood cultures also grew S. pneumoniae. Initial transthoracic echocardiogram was negative for endocarditis; however due to a high index of suspicion, a transesophageal echocardiography was performed and yielded a large mitral vegetation with anterior mitral valve leaflet perforation.
During her hospital course, she also started to have tenderness and swelling in the right SC joint. Further x-ray imaging was suspicious for a septic joint. She was initially treated with vancomycin and piperacillin-tazobactam, and this was subsequently narrowed to ceftriaxone following sensitivity results. She had a prolonged hospital course that required intravenous antibiotics, drainage of the right septic SC joint effusion and surgical replacement of her mitral valve. The patient had a dramatic clinical improvement during her hospitalization and was discharged home.
Discussion: Austrian syndrome, which is also known as Osler’s triad, is a very rare aggressive condition involving pneumonia, endocarditis, and meningitis caused by Streptococcus pneumoniae. It carries a high mortality and risk of severe complications. Our case presents a female who met the criteria for this rare syndrome and developed sternoclavicular (SC) septic arthritis. Only two prior case reports have described sternoclavicular septic arthritis as a complication of this Austrian syndrome. However, this is the first presentation in an immunocompetent patient with none of the typical risk factors such as chronic alcoholism, immunosuppression, intravenous drug use and splenectomy. The spread of the infection to extra-pulmonary sites such as the sternoclavicular joint was believed to be due to bacterial seeding in the setting of bacteremia and endocarditis, with the original origin of the infection being pneumonia.
Conclusions: This case illustrates that clinicians should maintain a high index of suspicion for sternoclavicular joint septic arthritis in patients with pneumococcal endocarditis and other features of Austrian syndrome, which is important for earlier detection and better outcomes in this rare condition.