Paediatric infective endocarditis presenting as intracranial haemorrhage: a medico-legal diagnostic challenge

Introduction: Intracerebral haemorrhage (ICH) and subarachnoid haemorrhage (SAH) in children represent diagnostic and medicolegal dilemmas, because more often than not, there is no history of trauma. Non-accidental injury (NAI)/ suspected physical abuse is often suspected in such cases, yet natural causes must not be ruled out completely. Infective endocarditis (IE), though rare in children, can lead to septic embolization and vascular rupture resulting in ICH and SAH, often mimicking traumatic head injury.
Case Presentation: This case study represents a ten-year-old girl who was admitted to a local hospital with loss of consciousness following a brief febrile illness. She was immediately transferred to the nearest tertiary care unit (National Hospital of Sri Lanka/ NHSL), and neuroimaging revealed right frontal ICH with SAH extension. Subsequent investigations demonstrated methicillin-sensitive Staphylococcus aureus (MSSA) bacteraemia and echocardiographic vegetations on the mitral valve, confirming IE. The child was treated with intravenous antibiotics and supportive care, and she eventually made a full recovery.
Conclusion: This case highlights the challenges in distinguishing natural from inflicted/traumatic paediatric haemorrhages and highlights the diagnostic value of multidisciplinary collaboration among forensic, paediatric, microbiology, and cardiology teams. Paediatric IE is rare because valvular endocardial damage and sustained bacteraemia seldom occur in healthy children; however, when it does, it usually involves a highly virulent organism or pre-existing cardiac anomalies. Awareness of this presentation prevents misinterpretation of infection-related brain bleed as child abuse, ensuring accurate medicolegal assessment.