It is essential to emphasize the likelihood of severe morbidity and mortality at the time of the initial presentation of the patient when he presented with septic arthritis. He was found to be bacteremic with S. pneumoniae and so the question arises, what was the pathogenesis of the septic arthritis? It is unequivocal that septic arthritis involving S. pneumoniae is the result of bacteremia and may in turn have contributed to the perpetuation of the bacteremia. In other words, patient had been bacteremic prior to the initial presentation in the emergency department and the bacteremia is almost certainly the result of primary respiratory infection which was apparent but not diagnosed at the initial presentation. S. pneumoniae resides in the upper respiratory tract and generally causes pneumonia, which I believed the patient had at the time of the initial presentation.
He certainly had an abnormal chest CT scan when he was admitted later. Moreover, he never died from the septic arthritis, the critical factor which contributed to the patient’s death was infective endocarditis with a devastating aortic valve infection. In all likelihood, this infection was also the result of the primary bacteremia secondary to the respiratory tract infection and it is more than likely that at the time of his first presentation with septic arthritis, that he already had cardiac valve involvement which progressed rapidly to cause his demise.
He almost certainly suffered from Austrian’s syndrome which is a triad of S. pneumoniae causing pneumonia, infective endocarditis, and meningitis. He had all three and therefore fits this diagnosis perfectly. The implication of this understanding, is that even if he had received high dose antibiotic therapy at the time of his initial presentation to the ED, (where the diagnosis of septic arthritis was missed) that he already had bacterial dissemination to other sites and that one could not state with greater than 50% probability that he would have survived had he been given high dose IV antibiotics at the time. He had a high mortality syndrome at his initial presentation.