Increase in Lymphadenitis Cases after Shift in BCG Vaccine Strain

Management of Bacille Calmette-Guérin Lymphadenitis and Abscess in Immunocompetent Children: A Systematic Review

BACKGROUND

There is no consensus on managing common adverse reactions to Bacille Calmette-Guérin (BCG) vaccination. We systematically reviewed the management of BCG-associated regional lymphadenitis and injection site abscess in immunocompetent individuals.

METHODS

Searches of Medline, Embase and PubMed were done until November 2020. Randomized controlled trials (RCTs) and cohort studies that compared management strategies for complications of intradermal BCG vaccination were included.

RESULTS

Of 1338 individual articles, 15 met inclusion criteria. Six RCTs, 4 prospective and 4 retrospective cohort studies compared management in 1022 children with BCG-associated lymphadenitis. For nonsuppurative lymphadenitis, no antimicrobial was found to significantly impact on time to resolution or prevention of suppuration. For suppurative lymphadenitis, there was some evidence that needle aspiration shortens time to resolution and prevents sinus tract formation. Surgical excision (mainly offered for persistent suppurative lymphadenitis) generally had favorable outcome. Two cohort studies (including 1 aforementioned) compared management strategies in up to 36 children with BCG injection site abscess; one showed no difference in outcome in children treated with antibiotics and the other reported complete resolution without treatment.

CONCLUSIONS

Evidence does not support a role for antimicrobial therapy in the management of localized reactions to BCG vaccination in immunocompetent children. Needle aspiration may shorten the recovery period for BCG-associated suppurative lymphadenitis. BCG injection site abscess usually heals without treatment. However, studies are limited and cases are not well defined. Growing research into novel BCG applications provides opportunities to investigate optimal management strategies for adverse reactions in a prospective manner using active safety surveillance.

Neonatal Bacille Calmette-Guérin vaccination and tuberculin skin test reactions at 2- and 6-months: Effects on mortality up to 1 year of age

BACKGROUND

In randomized trials, Bacille Calmette-Guérin (BCG) vaccine has been associated with reduced all-cause mortality. BCG-induced Tuberculin Skin Test (TST) reactions have also been associated with reduced all-cause mortality. We aimed to assess the association between TST responses and subsequent mortality in three birth cohorts and conducted a meta-analysis of existing studies.

METHODS

Observational study within three Guinea-Bissau BCG trial birth cohorts (conducted 2002-04, 2009-2013 and 2014-18) that encompassed children who were BCG-vaccinated within 28 days with TSTs performed at 2- (n = 1389) and 6-months (n = 2635) of age. We evaluated TST reaction determinants by binomial regression and assessed the association between TSTs > 1 mm (reactors) vs. ≤ 1 mm (non-reactors) and subsequent mortality risk up to age 12 months in Cox-models providing Mortality Rate Ratios (MRRs). We searched PubMed for studies to calculate meta-estimates of the association between TST reactivity by age 2- and 6-months and all-cause mortality.

RESULTS

Large post-vaccination wheal size was associated with 6-month TST positivity and so was receiving BCG-Denmark or BCG-Japan, compared with BCG-Russia. By age 2 months, 22% (302/1389) of infants were TST reactors with a 2-12-month mortality risk of 1.7% (5/302) vs. 3.3% (36/1087) for non-reactors, the corresponding reactor/non-reactor MRR = 0.49 (0.19-1.26). By age 6 months, 44% (1149/2635) of infants were reactors and the 6-12-month mortality risk was 0.4% (4/1149) vs. 0.6% (9/1486) for non-reactors, the MRR = 0.87 (0.27-2.86). The literature search provided 3 studies. The meta-analysis revealed a uniform pattern of reduced mortality associated with TST reactivity, a TST response by 2 months being associated with an MRR of 0.59 (0.39-0.90); for 6-month TST responses the MRR was 0.65 (0.43-1.00).

CONCLUSION

Among BCG-vaccinated infants, TST reactions were associated with markedly reduced mortality. Improved vaccination technique and using certain BCG strains could lead to a higher TST reaction prevalence, which would enhance BCG's beneficial non-specific effects.

Epidemiological characteristics and trends of Bacillus Calmette-Guérin lymphadenitis in Shanghai, China from 2010 to 2019

Although the administration of the Bacillus Calmette–Guérin (BCG) vaccine is generally safe, lymphadenitis, the most common complication of BCG vaccination, can occur. Here, we describe the epidemiological characteristics and incidence trends of BCG lymphadenitis in Shanghai, China, among a population with a high burden of tuberculosis. A total of 56 cases of adverse events following immunization (AEFI) after BCG vaccination were reported in Shanghai, including 51 cases of BCG lymphadenitis (91.07%), from 2010 to 2019. The general incidence of BCG lymphadenitis was 173 per 1,000,000 doses in Shanghai from 2010 to 2019. A nonsignificant increase of 58.81% per year was observed between 2010 and 2012 (t = 0.93; p = .40), followed by a significant decline of 28.00% per year from 2012 to 2019 (t = −4.27; p < .01). Seven batches of BCG vaccines triggered three or more BCG lymphadenitis cases, for 27 (52.94%) cases in total. We identified two patients with immunodeficiency of chronic granulomatous disease, one of whom died four years later after BCG vaccination and another of whom was still being treated after two transplants. The average total care cost of the 47 recovered cases was 11,336 RMB (range: 2,637–33,861 RMB). Due to the high burden of BCG lymphadenitis, especially in children with immunodeficiency, it is suggested that government departments should strengthen healthcare provider training, assign specific nurses to perform BCG vaccination, monitor vaccinated individuals actively and timely detect abnormal signals so as to reduce the incidence of BCG lymphadenitis.

Fine-needle aspiration cytology of Bacille Calmette-Guerin adenitis: A perplexing distinct clinical entity

BACKGROUND

Bacille Calmette-Guerin (BCG) adenitis is a common complication of post-BCG vaccination. Awareness of this lesser known entity in fine-needle aspiration (FNA) is important to prevent misdiagnosis.

AIM

This study described the clinical presentation, cytomorphological features and disease pattern in patients with BCG adenitis.

MATERIALS AND METHODS

We analyzed a series of 15 patients with BCG adenitis seen from July 2017 to July 2019. The detailed clinical and cytomorphology of these cases were studied.

RESULTS

Age of presentation ranged from 3 to 12 months. Male to female ratio was 2.75:1. A total of four children were diagnosed with primary immunodeficiency. Three children had acyanotic heart disease. Most of the children had left axillary lymph node enlargement. Cytomorphology showed the presence of polymorphs (66.7%), histiocytic aggregates (80%) and reactive lymphoid population (60%). Epithelioid granulomas (26.7%) and giant cells (6.7%) were present. The necrotic background was present in all but one case. Ziehl-Neelsen stain for acid-fast bacilli was positive in all but two cases.

CONCLUSION

A high index of clinical suspicion for BCG lymphadenitis should be kept in mind for patients who are recently vaccinated. FNA cytology, combined with clinical correlation, is useful for diagnosis and management.

BCG vaccination-induced suppurative lymphadenitis: four signs to pay attention to

Suppurative lymphadenitis is one of the severe complication after BCG vaccination, but its diagnostic criteria and treatment guidelines have not yet been established. In this article, we describe a case of suppurative lymphadenitis caused by BCG vaccination and propose diagnostic criteria and treatment guidelines of the disease. The lymphadenitis was presented as skin involving mass and was completely extirpated. Pathological evaluation revealed a necrotising lymphadenitis, consistent with the diagnosis of BCG lymphadenitis. The patient was administered adjuvant medical treatment with anti-TB medications (Isoniazid and Rifampicin) for 3 months. At 6 months follow-up, the disease was in complete remission without complications. We recommend focus on the following four signs when diagnosing BCG lymphadenitis: (i) previous history of vaccination on the ipsilateral side of the lesion, (ii) absence of any other infection signs, (iii) absence of fever and (iv) isolated axillary or supraclavicular/cervical lymph node enlargement proven by ultrasonography or computed tomography scan. BCG vaccination-induced suppurative lymphadenitis can easily be overlooked, but prompt, accurate diagnosis followed by appropriate surgical resection should result in complete healing as in this case.