Thread by @MayoClinicINFD

A series of images presented by an ID fellow to a faculty panel in the “Challenging Cases” session of the #MayoIDFellowsForum

The fellow asked the experts: What diagnosis comes to mind?

#IDTwitter, what do you think?
Clinical details, #MayoIDQ and MCQ to follow...

2/
Awesome list of potential pathogens... from staphylococcus / streptococcus to nocardia, TB, fungi (Mucor, Candida, endemics) and toxoplasma, and others.

Without knowing the host and scenario, all are possible. Thank you #IDTwitter.
Now let us learn about the case details..

3/
45M found unconscious.
PMH: alcohol use disorder. No IDU.
PE: T103F RR32 PR110
Meningismus.
Murmur. Rales.
No skin lesions.
WBC 27K.
Imaging (photo). No PFO.
CSF TNC 9450 /N92% /prot 150 / glu 20

Name the pathogen.

4/
Thank you for the replies.

This MCQ was an intense three-bacteria fight for the correct answer!

Streptococcus pneumoniae made a last-minute surge towards the end of the pool. :-)

5/
Let us first focus on who is the host and what is the syndrome?

Host: man with alcohol use disorder

Syndrome:
- Endocarditis (with septic emboli)
- Meningitis
- Pneumonia

Many of you suggested: #AustrianTriad

6/
Let us next focus on the risk: #Alcoholism

Alcohol can alter the actions of all cell populations involved in innate and adaptive immune responses.... enhance the susceptibility to bacterial infections

ncbi.nlm.nih.gov/pmc/articles/P…

7/
#Alcoholism increases risk of bacterial pneumonia

Meta-analysis showed an increased risk of pneumonia among alcoholic patients

dx.doi.org/10.1136/bmjope…

8/
What is the most common cause of #Pneumonia in #alcohol use disorder?

In a cohort study of 137,496 patients with pneumonia...

#Streptococcus pneumoniae is most common pathogen isolated as cause of pneumonia in patients with alcohol use disorder

jamanetwork.com/journals/jaman…

9/
#Alcoholism and Gram-negative pneumonia

In an analysis of community-acquired pneumonia and septic shock, a history of alcohol abuse was associated with infection caused by gram-negative organisms Pseudomonas aeruginosa and Acinetobacter species

doi.org/10.1053/jcrc.2…

10/
#Klebsiella pneumoniae is increased in patients with alcoholism

#Alcohol is associated with pneumonia, bacteremia and liver abscess due to Klebsiella pneumoniae

(But meningitis and endocarditis are very rare)

doi.org/10.1378/chest.…

wwwnc.cdc.gov/eid/article/8/…

11/
#Staphylococcus aureus is most common cause of native valve endocarditis
- May embolize to cause infections elsewhere, including brain (abscess and hematogenous meningitis) and the lungs

12/
#Staphylococcus aureus #meningitis
Two distinct syndromes/mechanisms
1. Postoperative
2. Hematogenous

In this case: it could be hematogenous S aureus meningitis, which has devastating clinical consequences and elevated mortality rates.

journals.lww.com/md-journal/Ful…

13/
#Staphylococcus aureus pneumonia

Is this primary pneumonia or septic emboli to the lung from endocarditis

Septic emboli to lungs in right-sided endocarditis. In this case: No IDU. No PFO.

For test-taking skills: if the Q drops hints (no IDU, no PFO) - believe it :-)

14/
Case resolution:
Blood and CSF culture: Streptococcus pneumonia
Rx: Ceftriaxone IV

Triad of pneumonia, endocarditis and meningitis - originally described by Osler, popularized by Austrian.

Thank you for your participation! 38% picked the correct answer.

15/
#AustrianSyndrome

Triad:
1. Pneumonia
2. Endocarditis
3. Meningitis

Cause: Streptococcus pneumoniae

Risks:
- Alcoholism
- Cirrhosis
- Functional asplenia
- ICH/HIV

/16
Endocarditis is least common among the Austrian triad.

Here is a contemporary review of #pneumococcal endocarditis
- 25% is part of Austrian Triad.
- Aortic valve involvement is most common.
- Meningitis is a risk for death.

ncbi.nlm.nih.gov/pmc/articles/P…