Neurological complications in children with infective endocarditis: Incidence, risk factors, and outcome: A 10-year single-center experience

Abstract

Background and objective: Despite improvement in medical management, infective endocarditis (IE) remains a serious disease that may affect children with and without preexisting cardiac conditions with significant morbidity and mortality. Neurological complications of IE represent the worst with guarded prognosis. The aim of this study is to describe the incidence, etiology, characteristics, risk factors, and outcome of children with neurological complications associated with IE.

Material and methods: A retrospective cohort study was conducted from 2009 to 2019 where all pediatric patients who fulfilled the modified Duke criteria for IE were included. We divided the cases into 2 groups: IE with neurological complications and IE without neurological complications control group. We compared the two groups statistically and analyzed the results.

Results: We identified 31 (17 male, 14 female) patients with IE. Neurological complications occurred in 7/31 (23%) patients, mainly in the form of a stroke. Gram-positive microbes were the main causative agents for IE (52%) followed by gram-negative (14%), then fungal organisms (3%). Univariate analysis identified the following risk factors for neurological complications: lower body weight, higher C- reactive protein (CRP) level, and left-sided valvular lesions with P values of (0.0003, 0.0001, and 0.04), respectively.Although mortality was higher in the neurological complications group, it was 43% in comparison to 21% in the control group and it did not reach statistical significance (P = .49). Large vegetation size (more than 10 mm) was seen in 57% of patients with neurological complications as compared to 16% in the control group (P = .052).

Conclusion: Neurological complications occurred in almost a quarter of children with IE. Possible risk factors include lower body weight, left-sided valvular lesion, and higher levels of inflammatory markers (CRP). Stroke was the most common neurological complication encountered with possible increased risk of mortality.

Keywords: CNS, Central Nervous System; CRP, C-reactive protein; ECMO, Extracorporeal membrane oxygenation; ESR, Erythrocyte sedimentation rate; IE, Infective Endocarditis; Infective endocarditis; MRSA, Methicillin-resistant Staphylococcus aureus; Neurological complications; PCICU, Pediatric cardiac intensive care unit; Pediatrics; WBC, White blood count; WBCs, White blood cells.

Fig. 1

Imaging of 5 patients with IE and neurological complications (a) Case 1: An 11-year-old boy, post-aortic valve replacement developed brucellosis IE that was complicated with multifocal infections in the left frontal lobe with abscess formation and adjacent gliosis.(b) Case 2: A 9-year-old boy, known to have congestive heart failure and multiple congenital heart diseases (Arcade mitral valve, severe mitral regurgitation, and atrial septal defect). He presented with symptoms of IE along with left-sided weakness and right facial weakness. Imaging was performed, which indicated a right thalamic infarct. (c) Case 3: A 4-year-old boy with coarctation of the aorta and atrial septal defect. He was diagnosed with fungal IE complicated with left-sided weakness and left middle cerebral artery stroke. (d) Case 4: Represents a 2-month-old boy known to have atrial septal defect diagnosed with MRSA sepsis IE, complicated with left frontal and partial subarachnoid hemorrhage. (e) Case 5: A 1-year-old girl, with Treacher Collins syndrome with bilateral anotia, Swiss cheese ventricular septal defects, and transposition of great arteries. The patient developed IE complicated with multiple septic infarctions and stenotic cavernous segment of the right carotid artery. (f) Case 6: A 5-year-old girl, not known to have any cardiac diseases, diagnosed with IE and complicated with right subclavian thrombosis. The patient developed seizure and hypotonia. Delayed myelination and hypoplasia of the corpus callosum were observed in her brain imaging.