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Chest wall granuloma associated with BCG vaccination presenting as hot abscess in an immunocompetent infant
© Lee et al.; licensee BioMed Central. 2015
Received: 24 September 2014
Accepted: 21 February 2015
Published: 4 March 2015
Bacillus-Calmette-Gue´rin (BCG) vaccine is a live attenuated vaccine to prevent tuberculosis by cell mediated immune response and is routinely administered early after birth. Although it is considered to be a very safe vaccine, sometimes a variety of complications may develop. Herein we describe a clinically unusual case of chest wall granuloma considered to be induced by BCG, presenting as hot abscess, and developed 7 months after BCG vaccination in an immunocompetent infant. The diagnosis was made based on the history, histopathology and virological studies. We suggest, although very rare, a BCG disease should be considered as a differential diagnosis in case of chest wall abscess, even if this is presenting as a hot abscess and even in immunocompetent infants if their age is related to BCG vaccination complications.
KeywordsBCG vaccination complication Hot abscess Chest wall abscess
Bacillus-Calmette-Gue´rin (BCG) vaccine is a live attenuated vaccine to prevent tuberculosis by cell mediated immune response and is routinely administered early after birth. Although it is considered to be a very safe vaccine, sometimes various complications may develop. Complications induced by BCG vaccine are very rare, estimated to be 0.01-3.6% . The most common complications induced by BCG vaccination are regional lymphadenitis and local subcutaneous abscess around the administration site. Herein, we report a clinically unusual case of chest wall granuloma considered to be induced by BCG, presenting as hot abscess, and developed 7 months after BCG vaccination in an immunocompetent infant.
Because there is still a high prevalence of tuberculosis in Korea, the BCG vaccination is administered to all healthy infants as early as after birth. The BCG vaccination complications are classified into five different types: (1) local disease, (2) regional disease, (3) distant disease, (4) disseminated disease, and (5) other BCG syndromes [2,3]. Among those complications, the most common type of complication induced by a BCG vaccination is a regional lymphadenitis and a subcutaneous abscess around the administration site. According to this classification, this case may be included in the distant disease type [2,3].
Even though a chest wall abscess induced by tuberculosis is very rare in an infant, a BCG vaccine complication or tuberculosis should be also considered in the differential diagnosis of a chest wall abscess in this age group . The tissue culture in a BCG- induced lymphadenitis is known to be negative for tuberculosis 20 weeks after the BCG vaccination . In the present case, tissue culture of the lesion was also negative several months after BCG vaccination. Meanwhile, in the present case, the chest CT showed a peripherally enhancing chest wall abscess in the subcutaneous layer infiltrating the pectoralis muscle, which is consistent with a caseous abscess induced by tuberculosis. Like in the present case, if a chest wall abscess presents without the isolation of any microorganism and histopathologic findings are shown consistent with a mycobacterial disease process, the possibility of a chest wall abscess induced by tuberculosis should be considered. Although tuberculosis was neither confirmed by culture nor PCR study, we concluded that the chest wall abscess was induced by a BCG vaccination possibly via an hematogenously spread mechanism, because of its histopathologic consistency with tuberculosis, no pulmonary parenchymal tuberculosis lesion, no isolation of microorganism including tuberculosis, the occurrence in a healthy infant and within 1 year of BCG vaccination and no contact to patients with tuberculosis. However, the exact pathogenesis remained unclear.
Granulomas in BCG diseases usually present as cold abscesses . However, our case interestingly appeared as a hot abscess with overlying cutaneous erythema, which is thought to be preceded by a cold abscess. And the erythema might result from the direct extension of the existing abscess inflammation to the overlying skin or a secondary other bacterial infection in the overlying skin and/or the abscess lesion, which is likely supported by the laboratory findings on admission.
In conclusion, although very rare, a BCG disease should be considered in the differential diagnosis of chest wall abscess, even if presenting as hot abscess, in infants, even immunocompetent, with an age related to BCG vaccination complications.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. This case study was approved by Institutional Review Board for Uijeongbu St. Mary’s Hospital (UC14ZISE0128).
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