Post-Bacillus Calmette-Gue´ rin lymphadenitis in Egyptian children: an outbreak
Background/purpose Intradermal vaccinations with Bacillus Calmette-Gue´ rin (BCG) give rise to a classic primary complex that consists of a cutaneous nodule at the site of injection and swelling of the regional lymph nodes. This study was performed to evaluate the clinical course of BCG lymphadenitis in relation to different management strategies and to assess the microbial resistance to an Indian BCG strain causing an Egyptian outbreak.
Patients and methods Prospective analytical follow-up of 152 patients with BCG lymphadenitis attending the Mansoura University Children Hospital between March 2010 and May 2011; of these, eight patients who had lymph nodes that were B1 cm in size (group A =5.3%) were managed with regular follow-up, 86 patients who presented with lymph nodes larger than 1–3 cm in size (group B=56.6%) received isoniazid and rifampicin for 6 months, and 58 patients who presented with lymph nodes larger than 3 cm in size or with BCG abscess or sinus (group C=38.1%) were subjected to early surgical excision.
Results Of the 152 patients, the male-to-female ratio was 1.7 : 1. The mean age was 5.97 months. The site of the lesions was the left axilla (132 patients, 86.84%), left supraclavicular (10 patients, 6.58%), cervical (four patients, 2.63%), and left axillary and supraclavicular (six patients, 3.95%). BCG lymphadenitis regressed spontaneously in four patients of group A (50%), 24 patients of group B showed an improvement in 6–9 months(27.9%), and progressive enlargement (44 cases, 51.2%) and development of BCG abscesses (18 cases, 20.9%) occurred in the rest of the patients who needed surgical treatment. For group C, surgical excision was performed from the start. Pathological examination was performed for all excised lymph nodes (124 patients, 81.6%) and revealed granulomas with extensive caseation necrosis. Microbiological examination was performed in all cases and revealed acid fast bacilli in 100 samples (80.6%) that were resistant to isoniazid, pyrazinamide, and streptomycin but sensitive to rifampicin only in 25 samples.
Conclusion As antituberculous therapy was found to be ineffective in the management of BCG lymphadenitis, we recommend a careful choice of BCG vaccines to avoid multidrug-resistant strains, early surgical excision of lymph nodes larger than 3 cm and lymphadenopathy complicated with abscess or sinus formation, and regular follow-up of smaller lymph nodes.
Keywords: Bacillus Calmette-Gue´ rinlymphadenitis, outbreak, tuberculosis, vaccination