Cardiogenic Shock in a Toddler With Rickets

Dilated cardiomyopathy (DCM) in pediatric patients is most commonly of idiopathic, genetic, or infectious etiology, but rare cases are reported secondary to vitamin D-deficient rickets. Mild rickets is typically associated with skeletal deformities, delayed gross motor milestones, and growth failure, while severe presentations may involve hypocalcemic seizures or DCM. We report a 16-month-old male patient presenting with lethargy, tachypnea, hypotension, and hepatomegaly who was found to have severe left ventricular dysfunction and associated cardiogenic shock. Initial management included intubation, inotropic support, and cannulation to venoarterial extracorporeal membrane oxygenation (VA ECMO). He had hypocalcemia on presentation, laboratory studies demonstrating a low vitamin D level, and radiograph findings of rachitic rosary, splaying of distal metaphyses, and generalized demineralization leading to a diagnosis of vitamin D-deficient rickets. Despite aggressive vitamin D and calcium repletion, the patient was unable to wean from VA ECMO, ultimately requiring transition to a Berlin Heart EXCOR pediatric left ventricular assist device (LVAD) on day 20 of hospitalization. The patient's hospital course was complicated by an LVAD-associated thromboembolic stroke with mild residual neurologic deficits after an unsuccessful mechanical thrombectomy. His left ventricular function gradually normalized, leading to successful explantation after 95 total days of mechanical support. The patient's left ventricular function remained normal at 1 year follow-up. This case highlights a rare but reversible cause of pediatric DCM and includes the use of LVAD support as a bridge to recovery in rickets-associated DCM.