OBJECTIVE: The objective of this review was to gain new insight into the rare condition, Austrian syndrome: the triad of endocarditis, meningitis and pneumonia caused by Streptococcus pneumoniae.
METHODS: A systematic review of case reports was conducted using the PRISMA guideline. Cases were rigorously screened to meet a set of well-defined inclusion criteria. Relevant data was aggregated and reported using descriptive statistics.
RESULTS: Seventy-one cases from 69 case reports were included in the final review. The mean age was 56.5 years with a male-to-female ratio of 2.4:1. Alcoholism was reported in 41% of patients. Altered mental state (69%) and fever (65%) (mean temperature on admission = 38.9°C) were the commonest presenting symptoms. The mean duration of symptoms before presentation to the hospital was 8 days. The aortic valve was most commonly affected (56%). The mean duration of antibiotic therapy was 5.6 weeks. Seventy percent of patients were admitted to the intensive care unit (ICU). Fifty-six percent of patients had valvular surgery. The average length of stay in the hospital was 36.9 days. Mortality was recorded in 28% of patients.
CONCLUSIONS: Austrian syndrome is rare but deadly. The true incidence is unknown but is commoner in middle-aged men and in alcoholics. Affected patients are usually critically unwell, often requiring ICU admission and prolonged hospital stays. Treatment is aggressive including prolonged courses of antibiotics and often, surgery. Despite these, the case fatality rate is high, with death occurring in over a quarter of patients. Surgery appears to be associated with better prognosis.

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An eleven month old girl was referred to the pediatric emergency department at Landspitali Hospital due to fever and lethargy. On examination she was acutely ill with fluctuating level of conciousness. She deteriorated quickly after arrival at the emergency department and was diagnosed with pneumococcal meningitis. In the past year several cases of bacterial meningitis have been diagnosed with Streptococcus pneumoniae as the most common pathogen. The disease causing serotypes have been serotypes that were not in the vaccine that was used in iceland and the Icelandic health authorities have decided to change the vaccination programme accordingly.

We present the cases of two otherwise healthy adults, one with meningitis and another with a subdural abscess, with both conditions attributable to Streptococcus pneumoniae. A 31-year-old man was admitted with a 3-day history of fever, headache, and vomiting. Physical examination revealed intermittent confusion, irritability, and neck stiffness. Cerebrospinal fluid (CSF) culture was positive for S. pneumoniae. Contrast-enhanced magnetic resonance imaging (C-MRI) revealed multiple small lesions on the bilateral frontal lobes. Intravenous ceftriaxone and vancomycin were administered, followed by intravenous moxifloxacin. His symptoms resolved within 3 months. Additionally, a 66-year-old man was admitted for acute fever with confusion, abnormal behavior, and a recent history of acute respiratory infection. Physical examination revealed confusion, neck stiffness, and a positive right Babinski sign. CSF metagenomic analysis detected S. pneumoniae. C-MRI disclosed left occipitotemporal meningoencephalitis with subdural abscesses. Intravenous ceftriaxone was administered for 3 weeks. His condition gradually improved, with resorbed lesions detected on repeat MRI. This study expanded the clinical and imaging spectra of S. pneumoniae meningitis. In healthy adults, S. pneumoniae can invade the brain, but subdural abscess is a rare neuroimaging manifestation. Early diagnosis of S. pneumoniae meningitis by high-throughput sequencing and flexible treatment strategies are necessary for satisfactory outcomes.

BACKGROUND: Children with nephrotic syndrome are at increased risk of infections, including bacterial peritonitis, pneumonia, and cellulitis. However, bacterial meningitis, a potentially life-threatening complication, has not been highlighted as an infectious complication of nephrotic syndrome in recent reviews. We report a very subtle and unusual presentation of bacterial meningitis in a child with nephrotic syndrome, which without a high index of suspicion, would have been missed.
METHODS: A 9-year-old African-American male with a history of steroid-dependent nephrotic syndrome presented to the nephrology clinic for routine follow-up. His medications included mycophenolate mofetil and alternate-day steroids. His only complaint was neck pain and stiffness that the mother attributed to muscle tightness relieved by massage. There was no history of fever, vomiting, headache, photophobia, or altered mental status. On physical examination, he was afebrile (99 °F), but had mild periorbital swelling and edema on lower extremities. He appeared ill and exhibited neck rigidity, and demonstrated reflex knee flexion when the neck was bent. Laboratory evaluation revealed leukocytosis, elevated C-reactive protein, hypoalbuminemia, and proteinuria. Cerebrospinal fluid suggested bacterial meningitis. The patient was treated with ceftriaxone and vancomycin. Both cerebrospinal and blood cultures grew Streptococcus pneumoniae; vancomycin was discontinued. The child completed a 2-week course of ceftriaxone and was discharged home.
CONCLUSIONS: A high index of suspicion is necessary in children with nephrotic syndrome treated with corticosteroids, as symptoms may be masked, and thus, a life-threatening disease be missed. Bacterial meningitis should be highlighted as a serious infection complication in children with nephrotic syndrome.

BACKGROUND There is a recognized association between bacterial meningitis and intracranial hemorrhage. However, acute neurological symptoms at presentation, with confirmation of hemorrhage on imaging, may delay further investigations, including blood culture for diagnosing an infection. This report presents a challenging case of Streptococcus pneumoniae meningitis in a 64-year-old woman who presented with symptoms of cerebellar hemorrhage. CASE REPORT This report describes a 64-year-old woman who had a medical history of untreated diabetes mellitus. She was brought to our hospital with headache and impaired consciousness, complicated with fever. Based on the hemorrhage in the left cerebellar hemisphere detected in the head CT findings, the patient was initially diagnosed with cerebellar hemorrhage. However, a positive blood culture after 12 hours of admission made the physician consider a central nervous system infection as the cause of the hemorrhage and perform a lumbar puncture. Therefore, the patient was diagnosed with acute bacterial meningitis caused by Streptococcus pneumoniae, and antibiotic treatment was started immediately. Although her general condition improved after antibiotic treatment, her mental status did not improve completely. CONCLUSIONS This report highlights that the clinicians should be aware that bacterial meningitis may result in intracranial hemorrhage. Patients with symptoms of a hemorrhagic stroke should be thoroughly investigated to avoid a delay in the treatment of infection.

OBJECTIVE: Providing country-specific estimates of case fatality and sequelae from bacterial meningitis (BM) is important to evaluate and monitor progress toward the World Health Organization\'s roadmap to \"defeating meningitis by 2030\".
METHODS: From 2016-2020, GERMS-SA conducted enhanced surveillance at 26 hospitals across South Africa. Episodes of laboratory-confirmed BM due to Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis were included. Risk factors for in-hospital death and sequelae at hospital discharge among survivors were analyzed.
RESULTS: Of 12,717 invasive bacterial infections reported nationally, 39% (4980) were from enhanced surveillance sites, including 4159 pneumococcal, 640 H. influenzae, and 181 meningococcal infections. BM accounted for 32% (1319/4159) of pneumococcal, 21% (136/640) of H. influenzae, and 83% (151/181) of meningococcal invasive diseases. Clinical data were available for 91% (1455/1606) of BM: 26% (376/1455) were aged <5 years, 50% (726/1455) were female, and 62% (723/1171) with known HIV results, were HIV-infected. In-hospital case fatality was 37% (534/1455), and 24% (222/921) of survivors had adverse sequelae. Risk factors for death included altered mental status, HIV infection, and comorbidities. Risk factors for adverse sequelae included altered mental status and antimicrobial nonsusceptibility.
CONCLUSIONS: BM in South Africa has a high case fatality, and adverse sequelae frequently occur among survivors. Those with comorbidities (including HIV) are at the highest risk.

UNASSIGNED: Streptococcus pneumoniae (S. pneumoniae) is the first leading cause of invasive diseases such as meningitis, bacteremia and pneumoniae in children. In this case we report an early neonatal respiratory distress revealing meningitis caused by S. pneumoniae Serotype 17F through vertical transmission, in the newborn of 3 hours of live.
UNASSIGNED: A male late preterm newborn was born by vaginal delivery at a gestational age of 34 weeks. At 3 hours of life, he was admitted for early moderate neonatal respiratory distress in the Neonatal Medicine and Resuscitation Service. Cerebrospinal fluid culture yielded S. pneumoniae belonging to serotype 17F while the blood culture was negative. The same pneumococcal serotype was recovered from the high vaginal swab of the mother. Both isolates were found susceptible to all tested antibiotics except tetracycline and chloramphenicol to which the strain was resistant. Antibiotherapy management of the child included ceftriaxone at 150mg/kg/day for 21 days, in combination with gentamycin at 5 mg/kg/day for 5 days. ciprofloxacin was added at 40mg/kg/day in two doses for a period of three weeks as the baby presented a hydrocephalus.
UNASSIGNED: This finding shows that clinical manifestations of neonatal pneumococcal meningitis may be atypical and/or misleading.

BACKGROUND: SARS-CoV-2 is the major cause of infections in humans since December 2019 and is top of the global health concern currently. Streptococcus pneumoniae is one of the leading pathogens of invasive bacterial diseases, including pneumonia, sepsis, and meningitis. Moreover, this bacteria is mostly responsible for secondary infections subsequent to post-viral respiratory disease. Co-infections with bacterial and viral pathogens are associated with severe course of the disease and are a major cause of mortality. In this report, we describe a rare case of COVID-19 patient with pneumococcal sepsis and meningitis of unsuccessful course.
METHODS: A 89-year-old man, not vaccinated against SARS-CoV-2 infection, was diagnosed with COVID-19 pneumonia. Patient required oxygen therapy due to respiratory failure. The initial treatment of viral infection with tocilizumab and dexamethasone allowed for the stabilization of the patient\'s condition and improvement of laboratory parameters. On the 9th day of hospitalization the patient\'s condition deteriorated. Consciousness disorders and acute respiratory disorders requiring intubation and mechanical ventilation were observed. Brain computed tomography excluded intracranial bleeding. The Streptococcus pneumoniae sepsis with concomitant pneumoniae and meningitis was diagnosed based on microbiological culture of blood, bronchial wash, and cerebrospinal fluid examination. Despite targeted antibiotic therapy with ceftriaxone and multidisciplinary treatment, symptoms of multiple organ failure increased. On the 13th day of hospitalization, the patient died.
CONCLUSIONS: Co-infections with bacterial pathogens appear to be not common among COVID-19 patients, but may cause a sudden deterioration of the general condition. Not only vascular neurological complications, but also meningitis should be always considered in patients with sudden disturbances of consciousness. Anti-inflammatory treatment with the combination of corticosteroids and tocilizumab (or tocilizumab alone) pose a severe risk for secondary lethal bacterial or fungal infections. Thus, treating a high-risk population (i.e. elderly and old patients) with these anti-inflammatory agents, require daily clinical assessment, regular monitoring of C-reactive protein and procalcitonin, as well as standard culture of blood, urine and sputum in order to detect concomitant infections, as rapidly as possible.

BACKGROUND: Treatment of patients with penicillin-resistant S. pneumoniae (PRSP) is complicated because of the relatively poor blood-brain barrier penetration of effective antimicrobials. Our case: A previously healthy 70-year-old woman, a traveler from China to Japan, was admitted to our hospital with fever and loss of consciousness. She has no history of pneumococcal vaccination. She was diagnosed with bacterial meningitis due to penicillin-and third-generation cephalosporin-resistant strains of S. pneumoniae. The patient was successfully treated with a combination therapy of vancomycin (VCM) and levofloxacin (LVFX) and recovered without any neurological sequelae. As the treatment of penicillin-and third-generation cephalosporin-resistant strains of S. pneumoniae meningitis remains unclear, we conducted a review of the reported cases of meningitis caused by penicillin- and cephalosporin-resistant S. pneumoniae.
METHODS: We performed a search using the keywords \"penicillin-resistant Streptococcus pneumoniae,\" \"meningitis,\" and \"pneumococcal meningitis\". We searched the electronic databases PubMed, Embase, and Ichushi from their inception to March 2020. Subsequently, two authors independently reviewed the resulting database records, retrieved full texts for eligibility assessment, and extracted data from these cases.
RESULTS: We identified 18 papers describing thirty-five cases of penicillin- and cephalosporin-resistant S. pneumoniae meningitis including our case. The patient\'s characteristics were; median age: 50 years, men:50%, 85% of cases received combination regimens of antibiotics: Ceftroriaxone (CTRX) plus VCM (20 cases), CTRX plus VCM plus rifampicin (RFP) (two cases), CTRX plus linezolid (one case), fluoroquinolones (two cases), carbapenems (six cases), Thirty-five percent received steroids. Twenty-four percent of patients died. Twenty-six percent of patients complicated neurological sequalae.
CONCLUSIONS: Combination therapy including VCM plus LVFX could be a treatment option.