Purulent Pneumococcal Pericarditis Presenting as Normotensive Cardiac Tamponade in Austrian Syndrome.

BACKGROUND: Austrian syndrome is a rare manifestation of invasive Streptococcus pneumoniae infection. Purulent pneumococcal pericarditis causing cardiac tamponade is an exceptionally uncommon but life-threatening complication. CASE SUMMARY: A 63-year-old unhoused woman presented with altered mental status and respiratory failure. Despite preserved blood pressure, electrocardiography demonstrated electrical alternans, and point-of-care echocardiography revealed cardiac tamponade. Pericardiocentesis yielded purulent fluid growing S pneumoniae. Systemic emboli and echocardiographic findings were consistent with Austrian syndrome complicated by purulent pericarditis and cardiac tamponade. Despite medical and surgical management, the patient developed refractory shock and died. DISCUSSION: Purulent pneumococcal pericarditis may present with tamponade despite normotension or hypertension. Early recognition and prompt drainage are critical. TAKE-HOME MESSAGES: Cardiac tamponade may occur despite preserved blood pressure. Electrical alternans and point-of-care echocardiography are key diagnostic clues. Purulent pericarditis often requires surgical drainage and carries high mortality.