Austrian syndrome, also known as Osler's triad, is a medical condition that was named after Robert Austrian in 1957. The presentation of the condition consists of

pneumonia Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severi ...

endocarditis Endocarditis is an inflammation of the inner layer of the heart, the endocardium. It usually involves the heart valves. Other structures that may be involved include the interventricular septum, the chordae tendineae, the mural endocardium, or the ...

, and meningitis, all caused by ''

Streptococcus pneumoniae ''Streptococcus pneumoniae'', or pneumococcus, is a Gram-positive, spherical bacteria, alpha-hemolytic (under aerobic conditions) or beta-hemolytic (under anaerobic conditions), aerotolerant anaerobic member of the genus Streptococcus. They ar ...

''. It is associated with

alcoholism Alcoholism is, broadly, any drinking of alcohol that results in significant mental or physical health problems. Because there is disagreement on the definition of the word ''alcoholism'', it is not a recognized diagnostic entity. Predomi ...

due to hyposplenism (reduced

splenic The spleen is an organ found in almost all vertebrates. Similar in structure to a large lymph node, it acts primarily as a blood filter. The word spleen comes .

functioning) and can be seen in males between the ages of 40–60 years old. Robert Austrian was not the first one to describe the condition, but Richard Heschl (around 1860s) or William Osler were not able to link the signs to the bacteria because microbiology was not yet developed.

Epidemiology

Signs of Austrian syndrome usually begin in Caucasian males over 40. A study shows that middle-aged men with alcohol issues make up most patients with Austrian syndrome.

Causes

The leading cause of Osler's triad (Austrian syndrome) is ''Streptococcus pneumoniae'', which is usually associated with heavy alcohol use. The condition was named ''Osler's triad'' because of its associations with pneumonia, meningitis, and endocarditis. Excessive consumption of alcohol would put the user at risk. It was determined that alcoholism completed the tetrad of associated conditions. The oldest recorded patient with Austrian syndrome had a history of health concerns such as hypertension, and

diabetes mellitus Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...

which increased her risk of Austrian syndrome.

Mechanism/pathophysiology

Osler's triad, also known as Austrian syndrome, was first introduced in the 19th century. ''

'' is the cause of Osler's triad of meningitis, pneumonia, and endocarditis. The portal of entry for this triad is said to be the lungs, followed by meningitis and endocarditis. Significant risk factors are heavy alcohol consumption, old age,

splenectomy A splenectomy is the surgical procedure that partially or completely removes the spleen. The spleen is an important organ in regard to immunological function due to its ability to efficiently destroy encapsulated bacteria. Therefore, removal of ...

immunosuppression Immunosuppression is a reduction of the activation or efficacy of the immune system. Some portions of the immune system itself have immunosuppressive effects on other parts of the immune system, and immunosuppression may occur as an adverse reacti ...

, etc. Endocarditis typically involves the

aortic valve The aortic valve is a valve in the heart of humans and most other animals, located between the left ventricle and the aorta. It is one of the four valves of the heart and one of the two semilunar valves, the other being the pulmonary valve. Th ...

. The native aortic valve is the most frequent vegetation site for ''Streptococcus pneumoniae'' and is considered the most common cardiac lesion. In fact it is a historic misnomer because Richard Heschl described the signs before Osler did, but he described this in german, so it got lost in the literature and the name was Osler's triad.

Signs and symptoms

The presentation of Austrian syndrome includes symptoms from all three of the triad:

, and meningitis. Cough-producing mucus, shortness of breath, and chest pains during cough are associated with pneumonia. Fever, muscle aches, swollen feet, and shortness of breath are some symptoms of endocarditis, and symptoms of meningitis like headache, confusion, sudden fever, and sensitivity to light.

Diagnosis

Early diagnosis of Austrian syndrome is beneficial. The disease is usually diagnosed later in an individual's life because it mostly affects older Caucasian men. Multiple tests are performed to determine if an individual has Austrian syndrome. Bacterial cultivation is the main method in diagnosing ''Streptococcus pneumoniae''.

Rapid diagnostic test A rapid diagnostic test (RDT) is a medical diagnostic test that is quick and easy to perform. RDTs are suitable for preliminary or emergency medical screening and for use in medical facilities with limited resources. They also allow point-of-care ...

is when a liquid sample of the ear or nasal discharge is collected. In terms of ''Streptococcus pneumoniae'', it is also used to confirm the causative bacterium.

X-Ray imaging Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical radiography ("diagnostic" and "therapeut ...

of the chest is performed to determine lung inflammation and

aortic regurgitation Aortic regurgitation (AR), also known as aortic insufficiency (AI), is the leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle. As a conseq ...

. Electrocardiogram is used to measure the sound waves of the heart. A physical exam is performed on lung and heart cavities and a spinal tap is also performed to collect

cerebrospinal fluid Cerebrospinal fluid (CSF) is a clear, colorless body fluid found within the tissue that surrounds the brain and spinal cord of all vertebrates. CSF is produced by specialised ependymal cells in the choroid plexus of the ventricles of the ...

Treatment

Since Austrian syndrome consists of meningitis, pneumonia and endocarditis, there are separate treatments for each. Pneumonia and endocarditis are usually treated with beta-lactam therapy penicillin, which has been said to be the most effective but sources have said that some bacterial strains are resistant to penicillin. High doses of penicillin do not affect pneumonia. Before penicillin was used for treatment, pneumococcus was a cause of several endocarditis cases. Also, for endocarditis, a valve replacement would be performed to avoid cardiogenic shock. For meningitis, intravenous antibiotics are used. Earlier studies suggest that dexamethasone improved the outcome of adults with

pneumococcal meningitis A pneumococcal infection is an infection caused by the bacterium ''Streptococcus pneumoniae'', which is also called the pneumococcus. ''S. pneumoniae'' is a common member of the bacterial flora colonizing the nose and throat of 5–10% of healthy ...

. In a specific case study, a patient who had symptoms of a fever and headache was treated with cefotaxime, ampicillin, and dexamethasone and had to undergo an emergency valve surgery since the EKG showed mitral vegetation.

Prognosis

In the 19th century, the mortality rate of Austrian syndrome was about 75%; it has since decreased to approximately 32%. The mortality percentage is higher in immunocompromised individuals. Austrian syndrome's symptoms, including

, and meningitis, all have high mortality rates.

Prevention

Decreased alcohol consumption is an effective way to lower the chances of developing Austrian syndrome. The incidence rate has reduced since the introduction of beta-lactam therapy in the early 1940s. Additionally, the introduction of the

pneumococcal vaccination Pneumococcal vaccines are vaccines against the bacterium '' Streptococcus pneumoniae''. Their use can prevent some cases of pneumonia, meningitis, and sepsis. There are two types of pneumococcal vaccines: conjugate vaccines and polysaccharide v ...

in 1977 further decreased the incidence of infection. However, 14% of patients don't have risk factors.

Research

Due to the rarity of the syndrome, with fewer than 60 cases reported, there has not been much research on the disease. But there have been multiple case studies that discuss certain treatments, preventions, diagnoses, depending on the individual. In a case study, an individual who had absolutely no history of alcohol abuse presented symptoms of the triad, such as low fever, myalgia, cough, breathlessness. He had abnormal pupils, which indicated injury to the brain. A CT scan was performed, and CSF analysis showed 78 cells/mm³ a low glucose concentration, and positive latex agglutination. The individual was treated with

Ceftriaxone Ceftriaxone, sold under the brand name Rocephin, is a third-generation cephalosporin antibiotic used for the treatment of a number of bacterial infections. These include middle ear infections, endocarditis, meningitis, pneumonia, bone and joint ...

which caused the aortic valve to swell up so

Vancomycin Vancomycin is a glycopeptide antibiotic medication used to treat a number of bacterial infections. It is recommended intravenously as a treatment for complicated skin infections, bloodstream infections, endocarditis, bone and joint infections, ...

and

Carbapenam A carbapenam is a β-lactam compound that is a saturated carbapenem. They exist primarily as biosynthetic Biosynthesis is a multi-step, enzyme-Catalysis, catalyzed process where substrate (chemistry), substrates are converted into more complex ...

were used next in the treatment process and the individual responded well and was able to recover at home with intensive therapy. So antibiotics are used as tools of treatment. In another case of Austrian syndrome, a 76-year old woman with diabetes mellitus, hypertension and chronic cervical and lumbar degenerative disease presented with the disease.