Transient heart stunning revealing an acute intracranial infection

Transient cardiac dysfunction can occur in the context of acute neurological conditions, namely neurogenic stunned myocardium (NSM). While this phenomenon is well-documented in adults with subarachnoid hemorrhage and stroke, it is rarely reported following central nervous system (CNS) infections, particularly in children. We conducted a retrospective review of pediatric cases admitted to our Pediatric Intensive Care Unit (PICU) between January 2013 and December 2023. We identified four cases (age range, 15 days to 8 years) of severe but transient myocardial depression presenting as the initial manifestation of acute CNS infections. All patients underwent comprehensive cardiac and neurological evaluations, including echocardiography, electrocardiography, cardiac biomarker assessment, and cerebrospinal fluid analysis. From 6120 total PICU admissions during this period, we identified four pediatric patients (0.065%) meeting our inclusion criteria. This represents an estimated incidence of NSM secondary to CNS infections of approximately 6.5 per 10,000 PICU admissions in our center. All patients presented with severe cardiogenic shock requiring intensive supportive care. The cardiac dysfunction was characterized by significantly reduced ejection fraction (range, 15-20%), elevated cardiac biomarkers (troponin I range, 0.8-3.2 ng/mL, normal < 0.04 ng/mL), and electrocardiographic changes. Cerebrospinal fluid analysis eventually confirmed CNS infections with various pathogens (Streptococcus viridans, Streptococcus pyogenes, Haemophilus influenzae, and Enterococcus faecalis). In all cases, cardiac function recovered completely within 3-7 days (mean, 4.5 days) while the underlying infection was being treated. No long-term cardiac sequelae were observed at hospital discharge.

This limited case series suggests that NSM may occur in pediatric patients with CNS infections. While these observations indicate that NSM could be considered in the differential diagnosis of acute heart failure in children, especially when accompanied by neurological symptoms or signs of infection, the small sample size and retrospective nature of our study require cautious interpretation. Larger prospective studies are needed to establish the true incidence, risk factors, and optimal management strategies for this condition.

•Neurogenic stunned myocardium (NSM) is a reversible cardiac dysfunction occurring after acute neurological insults, well-documented in adults following subarachnoid hemorrhage and stroke. •NSM can occur in pediatric patients with CNS infections and may present as severe myocardial depression before neurological symptoms become evident.

•This case series demonstrates that severe acute heart failure can be the initial presentation of CNS infections in children, with complete cardiac recovery occurring within 3-7 days. •Early recognition of NSM as distinct from primary cardiac causes can guide appropriate management focusing on the underlying neurological infection rather than solely on cardiac pathology.