Abstract

Introduction: Tuberculosis is a major cause of morbidity and mortality in developing countries including India. BCG vaccination is one of the important measures to decrease serious forms of tuberculosis i.e. military or disseminated tuberculosis especially in the pediatric age group. BCG vaccination was first included in the World Health Organization’s “Expanded Programme on Immunisation” in 1974. It is considered to be a safe vaccine as it has a very low incidence of serious side effects. Though the incidence of side effects is low, the mass administration means there are some effects which are bound to occur. BCG-Lymphadenitis is one such unusual complication. There are two types of BCG- lymphadenitis. Simple lymphadenitis and suppurative lymphadenitis. Simple BCG lymphadenitis usually doesn’t require any treatment and resolve on its own over a period of few weeks. Suppurative lymphadenitis on the other hand is characterised by appearance of erythema and other signs of inflammation over the skin overlying affected lymph nodes. Clinically fluctuation may be present in the swelling. The treatment of BCG adenitis has been controversial. In cases of simple lymphadenitis nothing is required and the adenitis is expected to resolve on its own in next few weeks. But in cases where the size of lymph node is more than 1.5cm and there is tenderness, fluctuation, signs of inflammation or sinus formation, antitubercular drugs are indicated.

Case Report: A 9 months old male child was brought to us with a history of gradually increasing swelling in left axillary region since 3 months. The swelling ruptured 10 days back draining a pus-like material. There was history of BCG vaccination to the child 3 months prior to the appearance of the swelling. There was no family history of tuberculosis. On examination, the baby was healthy and playful. BCG scar was present on left deltoid region. There was a non tender, fluctuant swelling with discharge in the left axillary region. The child was initially treated with oral Amoxicillin-Clavulanate but had no improvement. In view of history of BCG vaccination and classical clinical findings a provisional diagnosis of suppurative BCG lymphadenitis was made. Routine investigations and chest x ray were normal. USG of left axilla showed multiple enlarged necrotic lymph nodes. Left axillary lymph node biopsy was done. Biopsy specimen didn't show Acid Fast Bacilli on smear, but MTB was detected with no resistance to Rifampicin on Gene Xpert MTB RIF and Mycobacterium Tuberculosis Complex was isolated on culture. Category 1 antitubercular therapy was started for 6 months. Baby promptly responded to ant tubercular treatment and was discharged with an advice to complete the prescribed treatment.

Conclusion: BCG is usually considered a safe vaccine. Side effects following BCG vaccination are unusual but may occur. Non-suppurative BCG adenitis regresses spontaneously and usually no treatment is required. While suppurative lymphadenitis may require management in the form of antitubercular therapy. Immunodeficiency disorders should be excluded in children having severe suppurative lymphadenitis following BCG vaccination. Education and awareness of this entity in patients and paramedical personnel like anganwadi workers who are primarily involved in BCG vaccination in rural areas is essential to diagnose and treat this unusual complication of BCG vaccination

Keywords: BCG Adenitis, Gene Xpert, Antitubercular Treatment.