In practice, the diagnosis of HSP is usually based on the typical clinical presentation. It is essential to confirm leukocytoclastic vasculitis or proliferative glomerulonephritis with predominant deposition of IgA on histology, especially for patients with an unclear diagnosis or severe renal damage [1]. Currently, the European SHARE initiative recommends that skin biopsy is not required for typical palpable purpura on the lower limbs and buttocks [3]. HSP in children is usually self-limited, with 1/3 cases of recurrent purpura associated with renal involvement [1]. In this paper, we present a quite rare pediatric case of recurrent HSP combined with IE, and only a few adult cases of IE-associated HSP have been reported in the English literature [4]. Unfortunately, it is difficult to determine when the IE developed without a complete cardiac evaluation during the one-year course of the HSP for this girl. At least, the recurrent purpura may have something to do with IE, as the disappearance of purpura following the cure of IE could confirm this possibility, although the underlying mechanism is unknown.
IE is infrequent in children with an incidence of 0.3 to 3.3 per 100, 000 children and adolescents [5]. In the past 2 decades, congenital heart disease (CHD) has replaced rheumatic heart disease as the major predisposition for IE in children [6]. Abiotrophia defectiva is a Gram-positive streptococcus that colonizes in the oral cavity, gastrointestinal tract and urogenital tract of healthy individuals. It rarely causes IE that predominantly occurs in adults with structural heart disease, immunosuppression, prosthetic valves and invasive operations (such as dental procedures) [7, 8]. Atypical clinical presentation and fastidious nutritional make delays in the diagnosis and treatment of IE due to Abiotrophia defective [9, 10]. In addition, Abiotrophia defectiva is also a rare invasive organism predisposed to valve destruction, heart failure, systemic embolization and death as compared to other streptococci [10, 11]. Approximately 50% of patients with IE due to Abiotrophia defectiva require surgical intervention despite treatment with sensitive antibiotics [10].
IE caused by Abiotrophia defectiva is quite rare in pediatric cases, and it seems to be more devastating when compared to in adults. Since the definition of Abiotrophia defectiva was revised in 1995, including this case, only a total of 10 patients have been reported in the English medical literature [12]. The analysis of risk factors showed 4 cases (40%) with underlying CHD and 4 cases (40%) with a history of dental procedure. Right-sided valves were involved in 5 cases (50%), 4 of which had underlying CHD. Most patients present with a subacute course of atypical symptoms. In addition, nine of the ten (90%) cases developed complications, 7 (70%) of whom underwent surgery, while 4 of the 7 surgical patients underwent valve replacement due to severe valve destruction.
Valve replacement in children is always a challenge for cardiac surgeons because of the initial valve implant, small patient size, anatomy and growth potential. Without question, valvular repair is the goal of intervention because restoration of valvular anatomy and physiology using native tissue allows for growth and a potentially better long-term outcome [13].
Due to the high morbidity of complications associated with tricuspid valve replacement, it is rarely required to replace the tricuspid valve, particularly in children. In this case, the tricuspid valve structure suffered irreparable destruction, so valve replacement became inevitable. A bioprosthetic tricuspid valve replacement was used as an alternative for this girl.