A 74-year-old women with no history of interest was attended for pericardial pain with onset 3 days previously and no clinical signs or symptoms of infection and no fever. Of note was a discrete increase in troponin I and C-reactive protein and mild pericardial effusion in the echocardiogram.
The patient was diagnosed with myopericarditis and admitted to hospital. Anti-inflammatory treatment was initiated. After 24hours, the patient showed confusion, hypotension, and oliguria, although she remained afebrile. Pericardial effusion increased (figure 1) with generalized distribution and hypoechoic signal, and no clear signs of hemodynamic deterioration.
Given the neurological clinical picture, assessment by a neurologist was requested after cerebral computed tomography showed no findings of interest. Lumbar puncture was performed to take a sample of cerebral spinal fluid. Glucose, proteins, and cell count (7 leukocytes/mL) were normal. Given the oliguria despite saline administration, pericardiocentesis was performed using a subcostal approach, and a purulent exudate was obtained (figure 2). Examination under the microscope revealed the presence of Gram-positive cocci. Culture was positive for Streptococcus pneumoniae (figure 3). Culture of the cerebral spinal fluid was also positive for this bacterium.
The patient was admitted to the intensive care unit. Subsequently, pneumonia was diagnosed by thoracic computed tomography. Transesophageal echocardiography showed substantial calcification of the mitral valve, with no evidence of nodules. Cardiac positron emission tomography showed minimal uptake in the area of mitral calcification. This finding was difficult to interpret and did not confirm endocarditis.
This case corresponds to a variant of Austrian syndrome, consisting of a triad of meningitis, pneumonia, and purulent pericarditis.