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 ~  Abstract
 ~ Introduction
 ~ Discussion
 ~ Case Report
 ~  References
 ~  Article Figures

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  Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 33  |  Issue : 5  |  Page : 137-139
 

Suppurative supraclavicular bacille calmette-guerine lymphadenitis - A case report, awareness and management options


1 Department of Microbiology,Bharati Vidyapeeth Deemed University, Medical College and Hospital, Sangli, Maharashtra, India
2 Department of Public Health and Veterinary Public Health and Epidemiology, Rajiv Gandhi Institute of Veterinary Education and Research, Chennai, Tamil Nadu, India

Date of Submission08-Feb-2014
Date of Acceptance21-Mar-2014
Date of Web Publication6-Feb-2015

Correspondence Address:
U S Udgaonkar
Department of Microbiology,Bharati Vidyapeeth Deemed University, Medical College and Hospital, Sangli, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.150928

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 ~ Abstract 

Diagnosis of Bacille calmette-guerine (BCG) adenitis is clinical. Conventional laboratory tests do not differentiate BCG adenitis from tuberculous adenitis. We report a case of a 3-month-old healthy baby presenting with suppurative BCG adenitis. FNAC revealed AFB on ZN-Staining, later confirmed to be Mycobacterium bovis by multiplex PCR. The treatment of suppurative BCG adenitis is needle aspiration. Anti-tubercular treatment is unwarranted.


Keywords: Bacille calmette-guerine lymphadenitis, bacille calmette-guerine lymphadenitis management, suppurative bacille calmette-guerine lymphadenitis


How to cite this article:
Udgaonkar U S, Patil S S, Rekha V B, Shah S. Suppurative supraclavicular bacille calmette-guerine lymphadenitis - A case report, awareness and management options. Indian J Med Microbiol 2015;33, Suppl S1:137-9

How to cite this URL:
Udgaonkar U S, Patil S S, Rekha V B, Shah S. Suppurative supraclavicular bacille calmette-guerine lymphadenitis - A case report, awareness and management options. Indian J Med Microbiol [serial online] 2015 [cited 2019 Sep 16];33, Suppl S1:137-9. Available from: http://www.ijmm.org/text.asp?2015/33/5/137/150928



 ~ Introduction Top


Bacille calmette-guerine (BCG) is considered a safe vaccine; however, complications do occur some times. Lymphadenitis and suppuration is the commonest of them. Proper diagnosis and management of BCG lymphadenitis is important. Here we report a case of suppurative lymphadentis in an immunocompetent child.


 ~ Case Report Top


A three-month-old female child came to paediatric OPD with swelling in left supraclavicular region. The swelling was visible at the age of 6 weeks and gradually increased in size. The child had received BCG vaccine at the age of 2 weeks. There was no family history of tuberculosis. The baby was healthy and playful. BCG scar was on the verge of healing. Left supraclavicular region showed a round, non-tender fluctuant swelling of 3 cm size [Figure 1]. The overlying skin was not inflamed or adherent. Left axillary nodes were just palpable. Routine investigations and chest X-ray were normal; HIV test was nonreactive. The tuberculin test (5TU) was 14 mm with induration. USG neck showed bilateral multiple enlarged lymph nodes, largest on left side with collar stud abscess. Aspirate of the swelling did not show presence of bacteria on Gram stain; however, Ziehl-Neelsen (ZN) stain was positive for acid fast bacilli (AFB). As ZN smear was positive but culture follow-up negative, we considered molecular diagnosis. The reference mycobacterial strains used were M. tuberculosis H37Rv (MTCC) and M. bovis BCG vaccine strain obtained from Serum Institute of India. For molecular confirmation of Mycobacterium tuberculosis complex, genus-specific PCR was performed.
Figure 1: Left supraclavicular suppurative BCG adenitis

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From the sediment of the lymph node aspirate, DNA was extracted using QIAGEN DNA kit as per the manufacturer's protocol. PCR was performed in a total volume of 20 μl consisting of 3 μl of the sample template DNA, 10 μl of Red dye master mix (Amplicon), 5 μl of NFW and 5 pM each of the 2 primers targeting the IS6110 region, which included IS41-FP- 5′ CCT GCG AGC GTA GGC GTC GG 3′ and IS43-RP- 5′ TCA GCC GCG TCC ACG CCG CCA 3′, as per Liex Bana et al.[1] The cycling conditions were standardized as initial denaturation at 94°C for 10 minutes followed by 30 cycles of a denaturation step at 94°C for 2 minutes, primer annealing at 68°C for 2 minutes, extension at 72°C for 2 minutes and final extension at 72°C for 10 minutes. The amplicons were analysed by electrophoresis in 1.5% agarose gel. The amplification product was 317 bp, which was visualized using DNA from the sample specific for Mycobacterium tuberculosis complex. The sample was found positive for M. tuberculosis complex.

To differentiate M. tuberculosis and M. bovis, multiplex PCR was performed on extracted DNA from the aspirate as per Bakshi et al.[2] The total volume of 20 μl consisted of 3 μl of the sample template DNA, 10 μl of Red dye master mix (Amplicon), 4 μl of NFW and 5 pM each of the three primers including CSB1 Common FP (5′-TTCCGAATCCCTTGTGA-3′), CSB2 M.bovis RP (5′-GGAGAGCGCCGTTGTA-3′) and CSB3 M. tuberculosis RP (5′-AGTCGCCGTGGCTTCTCTTTTA-3′). These primers targeted a 229-bp sequence in M. bovis, which in the case of M. tuberculosis, is interrupted at position 197 by a unique 12.7-kb fragment ORFMTCY227.28c encoding a hypothetical protein 'Rv1506c' (accession no. Z79701). These complemented bases 312, 826-313, 088 of the M. tuberculosis gene [GenBank accession no. B×842576]. The product size amplified by CSB-1 and CSB-3 primers was 262 bp. The primer CSB-1 complemented bases 50-66 whereas the primer CSB-2 complemented bases 217-202 of the M. bovis gene [GenBank accession no. AJ003103]. The PCR product size generated by CSB-1 and CSB-2 was 168 bp. The cycling conditions were initial denaturation at 94°C for 5 minutes, followed by 30 cycles of a denaturation step at 94°C for 1 minute, primer annealing at 52.3°C for 1.30 minutes, extension at 72°C for 1 minutes and final extension at 72°C for 5 minutes. The amplicons were analysed by electrophoresis in 1.5% agarose gel. The unique amplification product of 168 bp identified it to be positive for M. bovis [Figure 2].
Figure 2: PCR amplification of Mycobacterium tuberculosis complex (lane 2) at 262 bp (base pair) region, BCG culture (lane 3) and baby sample (lane 4) at 168 bp region. Lane 1 shows 100 bp molecular weight ladder

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The child was initially treated with gentamicin. After our ZN report, clinicians referred the child to Directly Observed Treatment-Short course (DOTS) centre and switched over to Category I treatment of the Revised National Tuberculosis Control Programme (RNTCP) for 6 months. The swelling burst open draining a pus-like material. A follow up for one year was uneventful. An irregular scar developed at the abscess site later.


 ~ Discussion Top


BCG vaccination is used globally. After injection, the BCG strain starts multiplying rapidly at the site of inoculation and is transported through the lymphatics to the regional lymph nodes. The vaccine strain disseminates through blood to different organs forming small foci. This is normal reaction of BCG. The site of vaccination and glandular response forms a primary complex similar to that seen in natural tubercular infection. This reaction, a subclinical lymphadenitis, is not of much clinical importance as it regresses. [3] Review of literature showed that the lymph nodes commonly involved were ipsilateral axillary (92.3%), supraclavicular (3.8%) and supraclavicular with lower cervical (3.8%). Primary involvement of supraclavicular nodes without the involvement of axillary nodes is not common, seen in only 3.8-5% of the cases. [4],[5]

Lymphadenitis in this case developed around 6 weeks and progressed to suppuration within 3 months. Most of the workers reported development of lymphadenitis within a period of 2-6 months. [3]

Two types of BCG lymphadenitis have been recognized. The non-suppurative type occurring in the beginning resolves by itself in few weeks. It may progress to the second, the suppurative type which is marked by fluctuation and may have erythema, oedema of overlying skin. [5] It can form discharging sinus which take long to resolve or may heal with an ugly scar. [6] The diagnosis of BCG lymphadenitis is clinical. It is seen on the ipsilateral side of BCG vaccination and there is no other cause for lymphadenitis. Absence of fever, tenderness and other constitutional symptoms differentiates it from pyogenic adenitis. [5] The enlarged nodes are usually discrete and rarely matted. It cannot be differentiated from tubercular lymphadenitis on histopathology. [7] The risk factors for developing lymphadenitis can be host-related or vaccine-related. Vaccination during neonatal period has a high risk of lymphadenitis. Immunodeficiencies as seen in AIDS or Severe Combined Immunodeficiency Disease (SCID) have increased risk of local and generalised complications. A reactogenic strain, overdose of vaccine and inadvertent subcutaneous injections are the high risks for complications. [6] For optimum management of BCG adenitis, the question is to treat or not to treat. Non-suppurative lymphadenitis was believed to be an extended normal reaction to BCG vaccination and best left without antibiotics. It was also observed that the duration of lymphadenitis with isoniazid did not differ from those without isoniazid neither did isoniazid prevent suppuration. [8] Prevention of suppuration is the most important objective in treatment of BCG adenitis. Some cases tend to be obstinate, suppurated, forming abscess or fistula. When lymphadenitis developed rapidly, within two months and when the nodes were more than 3 cm, there were more chances of suppuration. Once suppuration occurred, the aim should be promoting resolution and preventing discharge and sinus formation. These were less likely to resolve spontaneously. They did not respond to medical treatment. For suppurative lymphadenitis simple needle aspiration was found useful, as regression was significantly faster than in non-treated group and spontaneous rupture was less frequent. [6],[9] Sometimes needle aspiration had to be repeated. Incision and drainage was universally condemned due to poor wound healing, persistent discharge, sinus formation, scarring and delayed recovery. Excision should be done as a last resort for failed aspirations as it required general anaesthesia. [5],[6]

Considering the high burden of tuberculosis, failure to protect infants against adult tuberculosis, the complications seen with BCG and parental concerns involved, India needs research on newer, safer and more efficacious vaccine. Recombinant BCG (rBCG) [10] is one such field which needs to be explored.

The case here is reported because microbiological diagnosis was given accurately by ZN staining. We believed the anti-tubercular regimen could have been deferred. Awareness and surveillance and generation of data on complications at the vaccination centres are very important. The reasons should be questioned, analysed and taken care of. Tertiary hospitals with vaccination centres can play a pivotal role. For treating BCG adenitis, one should differentiate normal reaction from an exaggerated reaction. Simple, non-suppurative lymphadenitis is a benign condition should be managed with reassurance, vigilance and masterly inactivity. In case it progresses to suppuration, therapeutic needle aspiration should be the first choice. Excision should be the last resort as it involves general anaesthesia. Incision drainage has no place in the treatment of suppurative lymph adenitis. Systemic treatment with anti-tubercular drug is ineffective.

 
 ~ References Top

1.
Liebana E, Aranaz A, Mateos A, Vilafranca M, Gomez-Mampaso E, Tercero JC, et al. Simple and rapid detection of Mycobacterium tuberculosis complex organisms in bovine tissue samples by PCR. J Clin Microbiol 1995;33:33-6.  Back to cited text no. 1
    
2.
Bakshi CS, Shah DH, Verma R, Singh RK, Malik M. Rapid differentiation of Mycobacterium bovis and Mycobacterium tuberculosis based on a 12.7-kb fragment by a single tube multiplex-PCR. Vet Microbiol 2005;109:211-6.  Back to cited text no. 2
    
3.
Ustevdt HJ. Local reactions in BCG vaccination. Bull World Health Organ 1950;2:441-68.  Back to cited text no. 3
    
4.
Behjati M, Ayatollahi J. Post BCG lymphadenitis in vaccinated infants in Yazd, Iran. Iran J Pediatr 2008;18:351-6.  Back to cited text no. 4
    
5.
Chan WM, Kwan YW, Leung CW. Management of bacillus calmette-guerin lymphadenitis. HK J Paediatr 2011;16:85-94.  Back to cited text no. 5
    
6.
Goraya JS, Virdi VS. Bacilli calmette-guerine lymphadenitis. Postgrad Med J 2002;78:327-9.  Back to cited text no. 6
    
7.
Yan JJ, Chen FF, Jin YT, Chang KC, Wu JJ, Wang YW, et al. Differentiation of BCG-induced lymphadenitis from tuberculosis in Lymph node biopsy specimen by molecular analysis of pcn A and oxy R. J Pathol 1998;184:96-102.  Back to cited text no. 7
    
8.
Seth V, Kabra SK, Seth R. BCG vaccination. In: Seth V, Kabra SK, editors. Essential of Tuberculosis in Children. 3 rd ed. India: Jaypee Publishers; 2006. p. 597-628.  Back to cited text no. 8
    
9.
Caglayan S, Arikan A, Yaprak I, Aksoz K, Kansoy S. Management of suppuration in regional lymph nodes secondary to BCG vaccination. Acta Paediatr Jpn 1991;33:699-702.  Back to cited text no. 9
    
10.
Velmurugan K, Grode L, Chang R, Fitzpatrick M, Laddy D, Hokey D, et al. Non clinical development of BCG replacement vaccine candidates. Vaccines 2013;1:120-38.  Back to cited text no. 10
    


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