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LETTER TO EDITOR
Year : 2021  |  Volume : 22  |  Issue : 2  |  Page : 181-182

Lymphadenitis and lichen scofulosorum following bacille calmette-guérin vaccination in an infant


1 Department of Dermatology, Lady Hardinge Medical College, New Delhi, India
2 Department of Paediatrics, Lady Hardinge Medical College, New Delhi, India
3 Department of Pathology, Lady Hardinge Medical College, New Delhi, India

Date of Submission06-Mar-2020
Date of Decision14-Apr-2020
Date of Acceptance12-May-2020
Date of Web Publication31-Mar-2021

Correspondence Address:
Suvarna Samudrala
Department of Dermatology, Lady Hardinge Medical College, Connaught Place, New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpd.IJPD_27_20

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How to cite this article:
Garg T, Samudrala S, Singh V, Agarwal S. Lymphadenitis and lichen scofulosorum following bacille calmette-guérin vaccination in an infant. Indian J Paediatr Dermatol 2021;22:181-2

How to cite this URL:
Garg T, Samudrala S, Singh V, Agarwal S. Lymphadenitis and lichen scofulosorum following bacille calmette-guérin vaccination in an infant. Indian J Paediatr Dermatol [serial online] 2021 [cited 2021 Jun 24];22:181-2. Available from: https://www.ijpd.in/text.asp?2021/22/2/181/312833



Sir,

Bacille Calmette-Guérin (BCG) vaccination can lead to various local and systemic complications that cause significant morbidity in children.

A 5-month-old male child presented with a swelling in the neck for 1 month, along with multiple tiny, grouped, raised lesions over the trunk and legs for 2 weeks, and signs of respiratory distress for 3 days. The child's uncle had completed antitubercular therapy 1 month ago for pulmonary tuberculosis (TB). The child had received BCG vaccination at the time of birth over the left arm.

On examination, the child had suppurative left supraclavicular and solitary left axillary lymphadenopathy, measuring 2 cm × 2 cm [Figure 1]a and [Figure 1]b. There were multiple grouped pinpoint hyperpigmented-skin-colored papules over the trunk and legs [Figure 2]a and [Figure 2]b. Erythema and induration measuring 1 cm × 1 cm was present over the BCG injection site over the left arm.
Figure 1: (a) Suppurative left supraclavicular lymphadenitis (b) Solitary nonsuppurative solitary left axillary lymphadenitis

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Figure 2: Multiple pinpoint hyperpigmented to skin coloured grouped papules over (a) the legs and (b) the trunk

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A provisional diagnosis of BCG adenosis and lichen scrofulosorum was made, and the child was further investigated for any systemic evidence of disseminated TB.

Routine investigations revealed low hemoglobin levels of 4.3 g/dl, total leukocyte count of 4810 cells/cumm, with lymphocytosis (absolute lymphocyte count-3992 cells/cumm). Chest X-ray showed consolidation of the right upper lobe, suggestive of pneumonia.

Fine-needle aspiration cytology done from the axillary lymph node showed acid-fast bacilli (AFB). Cartridge-based nucleic acid amplification test and AFB staining of the gastric aspirate were both negative. Enzyme-linked immunosorbent assay for human immunodeficiency virus in the child's mother was negative.

Skin biopsy showed basket weave orthokeratosis, and mild perivascular lymphocytic infiltrate, with no evidence of any granuloma or necrosis.

A final diagnosis of BCG adenosis and pneumonia was made. As the child had severe respiratory distress, which was not responding to systemic antibiotics, anti-tubercular therapy was started empirically, which led to a rapid decrease in the respiratory symptoms and lymphadenitis within a week, obviating the need for any aspiration or surgical intervention. The skin lesions also reduced rapidly, substantiating the clinical diagnosis of lichen scrofulosorum.

BCG vaccine has been in use since 1974 to control TB in endemic areas.[1] The incidence of local complications due to the BCG vaccine is approximately 1 in 1000 individuals. which is higher in younger ages, possibly due to impaired Th1 immunity.[2] Serious adverse events following BCG vaccination occur in immunodeficiency states.[3]

BCG lymphadenitis is the most common complication of BCG vaccination. It presents in two forms–simple or nonsuppurative lymphadenitis, which usually regresses spontaneously, or suppurative BCG lymphadenitis distinguished by the development of fluctuations, erythema, and edema of overlying skin. The time of onset is usually within 6 months. It may be treated by needle aspiration to prevent perforation and sinus formation.[4] Although there is no consensus as to what constitutes BCG lymphadenitis, the term has been recommended in cases where the lymph nodes are easily palpable and a cause of concern for the parents.[4]

Factors predisposing to lymphadenitis include the vaccine strain, its dose, viability and the age at vaccination. BCG vaccine given during the newborn period also increases the risk.[4]

Lichen scrofulosorum after BCG usually occurs after 1–4 months of vaccination at the affected site, and slowly involutes within months.[5] The onset of lymphadenitis and lichen scrofulosorum in our child was 5 months after vaccination.

Multiple treatments such as antitubercular drugs and oral erythromycin have not shown any significant effect in BCG-related complications.[5] In our patient, antitubercular drugs proved to be an effective treatment.

In our case, the absence of any immunodeficiency, late onset of lymphadenitis, and absence of dissemination of the disease were possibly responsible for the rapid recovery. Contrary to previous reports, antitubercular therapy proved to be effective in controlling the suppurative lymphadenitis in our patients.

We report this case due to the late onset of the skin lesions and lymphadenitis following BCG vaccination, and rapid response to antitubercular therapy, which has not been reported previously.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient's guardians have given their consent for their child's clinical information and images to be reported in the journal. The patient's guardians understand that their names and initials will not be published, and due efforts will be made to conceal the patient's identity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Govindarajan KK, Chai FY. BCG adenitis-need for increased awareness. Malays J Med Sci 2011;18:66-9.  Back to cited text no. 1
    
2.
Venkataraman A, Yusuff M, Liebeschuetz S, Riddell A, Prendergast AJ. Management and outcome of bacille calmette-guérin vaccine adverse reactions. Vaccine 2015;33:5470-4.  Back to cited text no. 2
    
3.
Apte AV, Sarkar S, Sarkar D. BCG adenitis: Action or inaction? J Evol Med Dent Sci 2014;3:3446-54.  Back to cited text no. 3
    
4.
Goraya JS, Virdi VS. Bacille calmette-guérin lymphadenitis. Postgrad Med J 2002;78:327-9.  Back to cited text no. 4
    
5.
Park YM, Kang H, Cho SH, Cho BK. Lichen scrofulosorum-like eruption localized to multipuncture BCG vaccination site. J Am Acad Dermatol 1999;41:262-4.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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