Background: The combination of endocarditis, pneumonia and meningitis caused by Streptococcus pneumoniae, currently known as the Austrian syndrome, is a rare condition with a high mortality rate. Case: We present the case of a 44-year-old man with a history of alcohol abuse who was recently treated with antibiotics for otitis media. The patient was admitted to our Intensive Care Unit with an impaired level of consciousness, respiratory insufficiency and sepsis. A pneumonia was diagnosed radiologically and molecular analysis of cerebrospinal fluid was positive for Streptococcus pneumoniae which necessitated treatment with intravenous antibiotics. Echocardiography showed a large mitral valve vegetation with severe mitral regurgitation. After two days on the ICU, due to increasing congestive heart failure, a mitral valve replacement was necessary. Unfortunately, our patient died four weeks post-admission due to a major myocardial infarction. Conclusion: The present case underlines the need to consider the possibility of endocarditis with potential valve damage in every patient with pneumococcal meningitis or bacteremia, particularly in those with a history of chronic alcohol abuse and in patients who are immunocompromised. By combining antibiotic treatment with valve replacement at an early stage, an improvement in mortality rates might be observed. © 2011, Nederlandse Vereniging voor Intensive Care. All Rights Reserved.