An Infant With BCG Adenopathy

An Infant was brought to the clinic by her concerned mother who has noticed a swelling in the baby's armpit while giving him bath yesterday. On history mother mentions the baby was given BCG vaccine a few weeks ago.

1. . What is this problem that occurred in this infant after few weeks of administration of BCG vaccine?
2. When it is more likely to occur?
3. What treatment should be offered to this infant?
4. What is the usual sequence of events after BCG vaccination?
5. What are the main advantages of BCG vaccine administration?

Answers:


1. . What is this problem that occurred in this infant after few weeks of administration of BCG vaccine?

Answer: This infant has developed BCG adenopathy. It is regional suppurative adenopathy in axilla following BCG vaccination. It is seen in 0.1-1% of babies after BCG vaccination. It does not indicate lowered protection afforded to this baby or a lowered immune response.

2. When it is more likely to occur? 

Answer: Ipsilateral cervical or axillary lymphadenopathy may develop a few weeks or months after BCG vaccination.

3. What treatment should be offered to this infant? 

Answer: These enlarged nodes regress spontaneously without any treatment after few months. Needle aspiration cytology if done would reveal presence of acid fast bacilli. But these are bovine vaccine bacilli and should not be inferred as tubercular disease and treated like it.
 Antitubercular therapy is of no benefit in such situations and should not be administered.

4. What is the usual sequence of events after BCG vaccination? 

Answer: Usually a papule forms after 2-3 weeks of administration of BCG which increases in size to 4-8 mm by end of 5-6 weeks. It later bursts to form an ulcer that heals in few weeks spontaneously leaving behind a scar.

5. What are the main advantages of BCG vaccine administration?

Answer: BCG vaccine has limited efficacy but it is only vaccine available against TB. It induces cell mediated immunity. Pulmonary TB protection is around 50%. Main advantage of BCG vaccination appears to be prevention of life threatening meningeal and miliary TB in infants and young children (50- 80%). BCG vaccination is recommended at birth. No tuberculin testing is required before administration of BCG. It can be given with other vaccines simultaneously or at any gap. But a gap of minimum 4 weeks should be kept between BCG and measles/MMR vaccine. BCG may be repeated once in children less than 5 years of age if no reaction or scar is seen after BCG vaccination presuming that BCG has not taken up. Even many of these patients have shown in vitro evidence of cell mediated immunity against TB. Tuberculin testing is not required prior to administration of second dose of BCG.