Bi-valvular pneumococcal endocarditis in Austrian syndrome, which includes a 
triad of pneumococcal endocarditis, pneumonia, and meningitis, is a rare but 
life-threatening disease. We present a case of a woman found to have Austrian 
syndrome who presented to the emergency department (ED) with dehydration and 
radiographical signs of lobar pneumonia and quickly deteriorated to fulminant 
cardiogenic shock in less than four hours. An early echocardiogram in the ED 
confirmed a diagnosis of bi-valvular endocarditis with severe aortic and mitral 
valve insufficiency and large vegetations on the valve leaflets requiring 
emergent surgical intervention with double valve replacement. Assumed meningitis 
as a part of the triad of Austrian syndrome was confirmed by imaging the day 
after hospital admission. Early diagnosis of endocarditis by obtaining the 
echocardiogram in the ED along with emergent surgical intervention allowed for a 
favorable outcome for the patient.