Chest Wall Abscess as a Complication of Bacilli Calmette–Guerin Vaccination in an Immunocompetent Child
A
15-month-old, otherwise healthy, boy was referred to the pediatric oncology department with the presumptive diagnosis of a chest wall tumor. He had been vaccinated with bacilli Calmette–Guerin (BCG) at 2 months of age, and there was no history of exposure and tuberculosis infection in his family. On physical examination, there was an immobile, firm mass on the anterolateral side of the left chest wall (Figure 1; available at www.jpeds. com). The patient had a BCG scar in his left deltoid region. Initial laboratory studies disclosed normal values for complete blood cell count, erythrocyte sedimentation rate, and C-reactive protein. Chest computed tomography (Figure 2) revealed a 30 42 28 mm cystic-necrotic lesion on the anterolateral side of the left chest wall. The lesion was excised, and histopathologic analysis showed a granulomatous infiltrate with central caseation necrosis and Langhans type giant cells, including the presence of acid-fast bacilli. The tuberculin skin test was nonreactive. Mycobacterium tuberculosis complex was cultured from the biopsy specimen and was further identified as a
strain of Mycobacterium bovis by polymerase chain reaction-mediated DNA-sequencing analysis. The patient was treated with isoniazid and rifampin for 6 months as an outpatient, and recovered without complications. During follow-up, all immunologic investigations were found to be normal, including the nitroblue tetrazolium test, peripheral blood lymphocyte subsets, in vitro lymphoproliferative response to mitogens, flow cytometric analysis of interleukin-12Rb1 cell surface expression on activated T cells, and interferon-gamma cell surface expression on monocytes. Serological testing for HIV was non-reactive. BCG vaccine has a good safety profile in immunocompetent children and considerable risks in individuals with immunedeficiencies. However, complications such as BCG lymphadenitis and abscess formation may occur in immunocompetent children.1-4 Chest wall abscess caused by Mycobacterium bovis BCG, although rare, should be kept in mind as a potential complication of BCG vaccination, and should also be considered in the differential diagnosis of the chest wall tumor. n Meltem Polat, MD Pediatric Infectious Diseases Department Gazi University Faculty of Medicine Ankara
Fatma Burcu Belen, MD Pediatric Hematology and Oncology Department Gaziantep Children’s Hospital Gaziantep, Turkey
References
Figure 2. Chest computed tomography, showing a cysticnecrotic lesion with peripheral and septal enhancement (white arrows). The lesion causes destruction of the eighth left rib.
1. Turnbull FM, McIntyre PB, Achat HM, Wang H, Stapledon R, Gold M, et al. National study of adverse reactions after vaccination with bacilli Calmette–Guerin. Clin Infect Dis 2002;34:447-53. 2. Aribas OK, Kanat F, Gormus N, Turk E. Cold abscess of the chest wall as an unusual complication of BCG vaccination. Eur J Cardiothorac Surg 2002;21:352-4. 3. Kim DH, Choi CW. Chest wall abscess likely due to BCG vaccination in a child. Infection 2009;37:286-8. 4. Talbot EA, Perkins MD, Silva SFM, Feothingham R. Disseminated BCG disease after vaccination. Case report and review. Clin Infect Dis 1997; 24:1139-46.
J Pediatr 2015;166:1319. 0022-3476/$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2015.01.030
1319
THE JOURNAL OF PEDIATRICS
www.jpeds.com
Vol. 166, No. 5
Figure 1. An immobile, firm mass (black arrow), approximately 4 3 cm in diameter, on the anterolateral side of left chest wall.
1319.e1
Polat and Belen
A
15-month-old, otherwise healthy, boy was referred to the pediatric oncology department with the presumptive diagnosis of a chest wall tumor. He had been vaccinated with bacilli Calmette–Guerin (BCG) at 2 months of age, and there was no history of exposure and tuberculosis infection in his family. On physical examination, there was an immobile, firm mass on the anterolateral side of the left chest wall (Figure 1; available at www.jpeds. com). The patient had a BCG scar in his left deltoid region. Initial laboratory studies disclosed normal values for complete blood cell count, erythrocyte sedimentation rate, and C-reactive protein. Chest computed tomography (Figure 2) revealed a 30 42 28 mm cystic-necrotic lesion on the anterolateral side of the left chest wall. The lesion was excised, and histopathologic analysis showed a granulomatous infiltrate with central caseation necrosis and Langhans type giant cells, including the presence of acid-fast bacilli. The tuberculin skin test was nonreactive. Mycobacterium tuberculosis complex was cultured from the biopsy specimen and was further identified as a
strain of Mycobacterium bovis by polymerase chain reaction-mediated DNA-sequencing analysis. The patient was treated with isoniazid and rifampin for 6 months as an outpatient, and recovered without complications. During follow-up, all immunologic investigations were found to be normal, including the nitroblue tetrazolium test, peripheral blood lymphocyte subsets, in vitro lymphoproliferative response to mitogens, flow cytometric analysis of interleukin-12Rb1 cell surface expression on activated T cells, and interferon-gamma cell surface expression on monocytes. Serological testing for HIV was non-reactive. BCG vaccine has a good safety profile in immunocompetent children and considerable risks in individuals with immunedeficiencies. However, complications such as BCG lymphadenitis and abscess formation may occur in immunocompetent children.1-4 Chest wall abscess caused by Mycobacterium bovis BCG, although rare, should be kept in mind as a potential complication of BCG vaccination, and should also be considered in the differential diagnosis of the chest wall tumor. n Meltem Polat, MD Pediatric Infectious Diseases Department Gazi University Faculty of Medicine Ankara
Fatma Burcu Belen, MD Pediatric Hematology and Oncology Department Gaziantep Children’s Hospital Gaziantep, Turkey
References
Figure 2. Chest computed tomography, showing a cysticnecrotic lesion with peripheral and septal enhancement (white arrows). The lesion causes destruction of the eighth left rib.
1. Turnbull FM, McIntyre PB, Achat HM, Wang H, Stapledon R, Gold M, et al. National study of adverse reactions after vaccination with bacilli Calmette–Guerin. Clin Infect Dis 2002;34:447-53. 2. Aribas OK, Kanat F, Gormus N, Turk E. Cold abscess of the chest wall as an unusual complication of BCG vaccination. Eur J Cardiothorac Surg 2002;21:352-4. 3. Kim DH, Choi CW. Chest wall abscess likely due to BCG vaccination in a child. Infection 2009;37:286-8. 4. Talbot EA, Perkins MD, Silva SFM, Feothingham R. Disseminated BCG disease after vaccination. Case report and review. Clin Infect Dis 1997; 24:1139-46.
J Pediatr 2015;166:1319. 0022-3476/$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2015.01.030
1319
THE JOURNAL OF PEDIATRICS
www.jpeds.com
Vol. 166, No. 5
Figure 1. An immobile, firm mass (black arrow), approximately 4 3 cm in diameter, on the anterolateral side of left chest wall.
1319.e1
Polat and Belen
