ABSTRACT
The Bacille Calmette-Guérin (BCG)-induced osteomyelitis is an extremely rare systemic adverse reaction after BCG vaccination in immunocompetent children and the correct diagnosis is frequently missed. We present 4 clinical cases of BCG-induced osteomyelitis reported over a 10-year period in a high-TB incidence country Lithuania. A brief review of clinical, management and treatment features of the disease is given.
Subject(s)
Antitubercular Agents/therapeutic use , BCG Vaccine/adverse effects , Osteomyelitis/etiology , Osteomyelitis/microbiology , Child , Female , Humans , Immunocompetence , Infant , Lithuania/epidemiology , Male , Osteomyelitis/drug therapy , Osteomyelitis/pathologyABSTRACT
BACKGROUND: In adults, anti-tumor necrosis factor-α (TNF-α) therapy is associated with progression of latent tuberculosis (TB) infection (LTBI) to TB disease, but pediatric data are limited. METHODS: Retrospective multicenter study within the Paediatric Tuberculosis Network European Trials Group, capturing patients <18 years who developed TB disease during anti-TNF-α therapy. RESULTS: Sixty-six tertiary healthcare institutions providing care for children with TB participated. Nineteen cases were identified: Crohn's disease (n = 8; 42%) and juvenile idiopathic arthritis (n = 6; 32%) were the commonest underlying conditions. Immune-based TB screening (tuberculin skin test and/or interferon-γ release assay) was performed in 15 patients before commencing anti-TNF-α therapy but only identified 1 LTBI case; 13 patients were already receiving immunosuppressants at the time of screening. The median interval between starting anti-TNF-α therapy and TB diagnosis was 13.1 (IQR, 7.1-20.3) months. All cases presented with severe disease, predominantly miliary TB (n = 14; 78%). One case was diagnosed postmortem. TB was microbiologically confirmed in 15 cases (79%). The median duration of anti-TB treatment was 50 (IQR, 46-66) weeks. Five of 15 (33%) cases who had completed TB treatment had long-term sequelae. CONCLUSIONS: LTBI screening is frequently false-negative in this patient population, likely due to immunosuppressants impairing test performance. Therefore, patients with immune-mediated diseases should be screened for LTBI at the point of diagnosis, before commencing immunosuppressive medication. Children on anti-TNF-α therapy are prone to severe TB disease and significant long-term morbidity. Those observations underscore the need for robust LTBI screening programs in this high-risk patient population, even in low-TB-prevalence settings.
Subject(s)
Latent Tuberculosis , Tuberculosis , Adolescent , Adult , Child , Humans , Interferon-gamma Release Tests , Latent Tuberculosis/diagnosis , Latent Tuberculosis/epidemiology , Necrosis , Retrospective Studies , Tuberculin Test , Tuberculosis/epidemiology , Tumor Necrosis Factor-alphaABSTRACT
Presented here is the case of a nine-month-old boy with the osteomyelitis of the upper area sternum caused by bacillus Calmette-Guerin (BCG), the Danish 1331 strain vaccine against tuberculosis. Upon examination, a swelling of approximately 2×3 cm diameter was observed in the upper sternal area. The mass was hard, fixed and sensitive to palpation with no local skin hyperaemia. Chest X-rays revealed a round mass anterior to the sternum, suggesting a diagnosis of osteomyelitis. A consequent sternal biopsy was performed and Mycobacterium bovis BCG was identified by a positive growth culture.
