Title Bacille calmette-Guerin (BCG) associated lymphadenitis

Author(s) Ho, Po-ki, Polly; 何寶琪

Citation

Issued Date 2011

URL http://hdl.handle.net/10722/173732

Rights Creative Commons: Attribution 3.0 Hong Kong License

1

Bacille Calmette-Guérin(BCG) associated lymphadenitis

By

Ho Po Ki

1999119193

Department of Paediatrics

Queen Elizabeth Hospital

This work is submitted to

Faculty of Medicine of The University of Hong Kong

In partial fulfillment of the requirements for

The Postgraduate Diploma in Infectious Diseases, PDipID (HK)

Date: 30.6.2011

Supervisor: Dr V Cheng

2

Declaration

I, Ho Po Ki, declare that this dissertation represents my own work and that it has not

been submitted to this or other institution in application for a degree, diploma or any

other qualifications.

I, Ho Po Ki, also declare that I have read and understand the guideline on “What is

plagiarism?” published by The University of Hong Kong (available at

http://www.hku.hk/plagiarism/) and that all parts of this work complies with the

guideline.

Candidate: Ho Po Ki

Signature:

Date:

30.6.2011

3

Abstract

Background: Excluding local reaction, regional lymphadenitis is the most common

adverse events after BCG vaccination. It is the development of ipsilateral regional

lymph node enlargement following BCG vaccination. Some progress to suppuration.

If left untreated, suppurative lymphadenitis frequently ruptures with sinus formation,

ending in prolonged course of illness and scaring.

Objective: To describe the clinical features and outcome of children with suppurative

lymphadenitis after BCG vaccination. To identify factors associated with the duration

of healing and scarring formation.

Method: Patients diagnosed suppurative BCG lymphadenitis in a tertiary paediatric

centre from January 2004 to April 2011 were identified. Data on demographics,

clinical features, treatment received and outcomes were retrieved from medical

records.

Results: There were 15 cases of BCG suppurative lymphadenitis during the period.

11(73.3%) were males. All had their BCG vaccinated at birth. The mean age of

presentation was 5.8±6.6 months (median 3 months). All presented with a solitary

swelling over ipsilateral axilla(80%) or supraclavicular region without systemic

symptom. The mean size of lymph nodes were 2.1cm±0.8cm times 1.8cm±0.8cm. All

except 1 had a normal chest X-ray. The mean total white cell counts and mean

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lymphocyte counts were 13.0x109/L and 7.3x109/L respectively. 7/13(53.8%) patients

were smear positive for acid-fast bacilli and 2/13(15.4%) were culture positive for

Mycobacterium bovis. 12(80%) patients had single needle aspiration performed while

the other 3 patients did not receive intervention. No patient required surgical excision.

5(33.3%) patients had spontaneous rupture and discharge. 2(13.3%) patients had sinus

formation with persistent discharge for long duration. All patients completely healed

subsequently. The mean duration of complete healing was 4.5 ± 1.7 months.

8/13(61.5%) patients had subsequent scarring. The duration of healing was not

associated with sex, age, time since BCG vaccination, white cell and lymphocyte

count, site of lymph node, size of lymph node, presence of spontaneous rupture, sinus

formation or needle aspiration. The size of lymph node at presentation was

significantly larger in patients with scarring (2.4±0.8cm vs. 1.3±0.4cm, p=0.026). On

the other hand, sex, age, site of lymph node, white cell and lymphocyte count,

presence of sinus formation, spontaneous rupture, needle aspiration and duration of

healing showed no correlation with scarring.

Conclusion: Suppurative lymphadenitis is not an uncommon complication of BCG

vaccination. The diagnosis is clinical and should be suspected in children present with

ipsilateral axilla, occasionally supraclavicular lymph node enlargement with history of

BCG vaccination. A chest X-ray is recommended for all patients while tuberculin skin

5

test has no diagnostic use. The low positive microbiological yield in aspirate

highlights that negative smear or culture does not rule out the diagnosis. Needle

aspiration is safe and is the main stay of treatment. Surgical excision is reserved for

those who failed repeated needle aspirations. The size of lymph node was

significantly associated with subsequent scarring formation.

(468 words)

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Background

Bacille Calmette-Guérin (BCG) vaccine is one of the most widely used vaccine

worldwide. It has been used to prevent tuberculosis since 1921 and included as part of

the immunization programme of the World Health Organization since 1974. It was

proven to be effective against tuberculous meningitis and disseminated tuberculosis,

with an estimated efficacy of 64% and 78% respectively. [1] BCG vaccine was

incorporated in Hong Kong’s routine newborn immunization programme. Over 99%

of babies in Hong Kong receive the vaccine at birth. Besides newborns, BCG

vaccination is also recommended for children aged less than 15 who reside in Hong

Kong and do not have BCG vaccination before. [2] BCG vaccine is a live-attenuated

vaccine derived from bacterial isolate of Mycobacterium bovis, which is cultured in

vitro for many years. There are many strains and strength of BCG vaccine. Different

strains were noted to have varied potency and complications rate. One of the common

strains used in Hong Kong is the Copenhagen strain 1331.

BCG vaccine carries a low risk of serious complications and is regarded as a

safe vaccine. [3] Mild local reactions in terms of erythema or induration are the most

common adverse events following BCG vaccine. Ulceration and abscess formation

are serious yet uncommon local complications. Following local reaction, regional

lymphadenitis is the second most common adverse events associated with BCG

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vaccination. A recent prospective large scale study involving a 12-month cohort

follow up of 2435 BCG-vaccinated children found that the incidence of local

erythema, induration and lymphadenitis were 12.4%, 12.2% and 0.1% respectively.

[4]

BCG lymphadenitis is the development of ipsilateral regional lymph node

enlargement following BCG vaccination. Indeed, the BCG starts to multiply quickly

at the site of infection and transported through the lymphatic systems to regional

lymph nodes after inoculation, causing enlargement of the corresponding lymph

nodes. Slight subclinical enlargements of lymph nodes are common after BCG

vaccination and they regress spontaneously without treatment. Unfortunately,

standardized criteria to define what constitutes a pathological BCG lymphadenitis are

lacking. It is commonly regarded as the enlargement of lymph nodes that are large

enough to be easily felt and cause parental concern. [5] BCG lymphadenitis can be

broadly classified into two groups: non-suppurative and suppurative. Non-suppurative

lymphadenitis either regresses spontaneously within weeks without medical

intervention, or progresses to development of suppuration to form the latter. Singla

and coworkers found 85% of patients had spontaneous regression of BCG

lymphadenitis while the remaining 15% progress to suppuration. [6] If left untreated,

suppurative lymphadenitis frequently ruptures with sinus formation, leaving scaring

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and even keloid formation. Moreover, it is associated with an unpleasant and

prolonged course of illness. In the present study, we focus on the analysis of

suppurative BCG lymphadenitis in our locality, as non-suppurative lymphadenitis

carries little clinical significance.

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Objective

The present study aims to describe the clinical features and outcome of children

with suppurative lymphadenitis complicating BCG vaccination. The factors

associated with the duration of healing and subsequent formation of scarring are also

explored. Furthermore, current literature on BCG lymphadenitis is reviewed.

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Methodology

We identified patients with suppurative BCG lymphadenitis in a tertiary

paediatric centre Queen Elizabeth Hospital from January 2004 to April 2011. The

diagnosis of suppurative BCG lymphadenitis was clinical, by paediatric infectious

disease specialists in the department. Data on demographics, clinical features,

treatment received and outcomes were retrieved from medical records. Copenhagen

1331 strain were universally used in the hospital, of which 1 ml reconstituted vaccine

contains 2 to 8 million colony forming units of Mycobacterium bovis. The dosage was

0.05ml administered intradermally.

Descriptive data are expressed as mean ± standard deviation. Categorical

variables are compared by Chi-square test or fisher exact test where appropriate.

Independent sample T-test or Mann-Whitney U test is used to compare variables

between patient with and without scarring. Pearson’s correlation coefficient or

Spearman correlation coefficient is used to explore associations between variables and

healing time. SPSS 16.0 is used for statistically analysis. A p value of <0.05 is

regarded as statistically significant.

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Results

There were 15 cases of BCG suppurative lymphadenitis presented during the

period from January 2004 to April 2011. 11(73.3%) of them were males. All of them

received BCG vaccination at birth. The mean age of presentation was 5.8±6.6 months

(median 3 months). The mean duration of onset after vaccination was 5.8±6.6 months

(median 3 months). The age of presentation ranged from 2 months to 26 months of

age. Table 1 summarized the clinical characteristics of the 15 patients with BCG

suppurative lymphadenitis. All patients presented with a swelling either over axilla or

supraclavicular region. The duration of symptoms of presentation ranged from 1 day

to 4 weeks. All patients were afebrile and did not have other constitutional symptom.

Their growths were normal.

Concerning about the characteristics of lymph nodes, all of them were located

over the ipsilateral side (left side) of BCG inoculation. All patients presented with a

solitary lymph node. 12 (80%) were in the axilla region, while the remaining 3 were

in the supraclavicular region. All the lymph nodes were soft, fluctuant and

accompanied with local erythema. All had absence of tenderness and local increase in

temperature. The mean 2-dimensional size of lymph nodes were 2.1cm±0.8cm and

1.8cm±0.8cm. Figure 1 demonstrated the typical appearance of a BCG associated

suppurative lymphadenitis.

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All patients had chest X-ray performed. All chest X-rays showed no abnormal

pulmonary infiltrate or intrathoracic lymph node enlargement. 1 patient (case 7) had

calcification identified in the left axilla region from the chest X-ray. (Figure 2) The

mean total white cell counts were 13.0x109/L, while the mean lymphocyte counts

were 7.3x109/L. All cases’ C-reactive protein levels were within normal range.

Tuberculin skin test was performed in 1 patient only, which yielded a positive result at

48 hours(15mm induration). 2 patients’ lymph node discharges were unavailable for

microbiological tests as needle aspiration were not done and the lymph nodes healed

without spontaneous rupture. Among the remaining 13 cases where their discharge

were tested, 7(53.8%) were smear positive for acid-fast bacilli and 2(15.4%) yielded

positive culture for Mycobacterium bovis. No immune workup was performed in our

cases.

Referring to the treatment received, 12(80%) patients had needle aspiration

performed while the other 3 patients did not receive intervention. None had

complication regarding needle aspiration and the procedure was well tolerated. No

patient required surgical excision. None of the patients were given anti-tuberculous

drug except 1 patient whom was given 3 weeks of isoniazid by a private doctor (case

14). The anti-tuberculous drug was discontinued upon referral to our hospital.

Among the 15 cases, 5(33.3%) patients had spontaneous rupture and discharge.

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2(13.3%) patients had sinus formation with persistent discharge for long duration. 2

patients defaulted follow up after initial presentation. All the other patients were

regularly followed up till complete resolution of the enlarged lymph nodes. The mean

duration of complete healing was 4.5±1.7 months. 8(61.5%) among the 13 patients

were complicated with scarring.

The factors associated with the duration of healing and subsequent formation of

scarring were explored. As shown in table 2, the duration of healing were compared

between patient groups stratified by sex, site of lymph nodes (axilla vs. supravicular),

size of lymph nodes (<2cm vs. ≥2cm), presence of spontaneous rupture, sinus

formation and needle aspiration. All the healing times were not significantly different

among these group stratifications. On further statistical correlation, the size of lymph

node at presentation (p = 0.66), age at presentation (p=0.96), duration since BCG

vaccination (p=0.96), white cell count (p=0.13) and lymphocyte count (p=0.10) did

not correlate with the duration of healing.

Clinical parameters were compared among patients who left with scarring and

those without. The size of lymph node at presentation was significantly larger in

patients complicated with scarring (2.4±0.8cm vs. 1.3±0.4cm, p=0.026). On the other

hand, sex(p=1.00), age at presentation(p=0.87), site of lymph node(p=0.51), white cell

count(p=0.83), lymphocyte count(p=0.89), presence of sinus formation(p=0.49),

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presence of spontaneous rupture(p=0.075), needle aspiration done(p=0.51) and

duration of healing(p=0.92) were similar among the 2 groups. The results were shown

in details in table 3.

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Discussion

Bacille Calmette-Guérin(BCG) lymphadenitis is one of the commonest

complication of BCG vaccination. The present study described the clinical features

and outcome of children with suppurative lymphadenitis after BCG vaccination. The

factors associated with the duration of healing and subsequent formation of scarring

were also explored.

The diagnosis of BCG lymphadenitis is largely clinical. It was suggested that

with a background history of BCG vaccination, the finding of an ipsilateral lymph

node enlargement without other identifiable cause of lymphadenitis rendered

sufficient grounds to make the diagnosis. [7] One of the major differentials is

pyogenic adenitis. The absence of increase in local temperature, tenderness,

constitutional symptoms and fever point away from the diagnosis of pyogenic adenitis,

although one should bear in mind that superimposed bacterial infection or

co-infection in BCG lymphadenitis does happen rarely. Differentiation from

non-tuberculous mycobacterial or tuberculous lymphadenitis can be challenging, but

fortunately cases presented as solitary lymph node are very scarce. The main stay of

presentation of BCG lymphadenitis is a swelling over ipsilateral lymphatic drainage

region. Multiple lymph nodes are found in rare occasions. Our findings of all patients

being presented with a solitary lymph node over ipsilateral side without systemic

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symptom corroborated with previous studies. Previous data suggested that the mean

age of onset of BCG suppurative lymphadenitis was 2 to 4 months after BCG

vaccination, although cases presented at 24 months post-vaccination had been

reported. [5] The current study’s finding of a median duration of presentation of 3

months after vaccination, ranging from 2 months to 26 months, is consistent with the

literature. Interestingly, our study noted the supraclavicular lymph node was involved

in 20% of cases, in contrast to previous reports which stated axilla lymph node being

involved in over 95% of cases. [5] It may partly be related to the easier and earlier

identification of supraclavicular lymph nodes due to its explicit location. It had also

been proposed that the higher the BCG injection site above the level of deltoid tendon

insertion, the more likely the involvement of cervical and supraclavicular lymph

nodes. In fact, BCG injection site should always be over the insertion of the deltoid

muscle where the drainage from this region only reaches the axilla lymph nodes. The

finding of lymphadenitis in other areas like cervical or supraclavicular region signifies

faulty site of injection. However, this is difficult to verify in our study as there is no

clear documentation of site of injection in the cases.

Further investigations added little diagnostic information. Tuberculin skin test is

not helpful in making the diagnosis of BCG lymphadenitis as the test is positive with

recent history of BCG vaccination in immunocompetent patient, which corresponds to

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the most commonly affected patient group. Furthermore, it cannot differentiate

Mycobacterium tuberculosis and Mycobacterium bovis infection as both induce a

positive tuberculin skin test result. On the other hand, the absence of tuberculin skin

test reaction in a patient with recent history of BCG inoculation should prompt

workup for underlying immunodeficiency. Indeed, routine immune workup is not

required unless in disseminated BCG infection or atypical features present. [8] A

simple chest X-ray is recommended in all cases to look for abnormal pulmonary

infiltrate or intrathoracic lymph node enlargement, which suggested disseminated

BCG disease or tuberculosis. In our study, chest X-rays were universally performed in

all our patients and were normal except 1 which we previously described. Lymph

node aspirate occasionally has positive microbiological yield, yet bacteriological

confirmation is not required to make the diagnosis. Smear of aspirate from lymph

nodes may yield acid-fast bacilli and culture may yield Mycobacterium bovis.

Although the yield of positive smear and culture is generally commented as low, the

exact data is limited. We reported a rate of 53.8% for positive AFB smear and 15.4%

for positive Mycobacterium bovis culture. These data reinforces the important concept

that a negative smear or culture cannot rule out the diagnosis of BCG lymphadenitis.

The common cytology patterns of BCG lymphadenitis are the identification of

acid-fast bacilli(AFB) in a necrotic background, granulomas with necrotic areas and

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granulomas in a reactive lymphoid background. However, these features cannot help

distinguish BCG lymphadenitis from tuberculosis lymphadenitis as the

cytomorphologic patterns are similar in both groups. [9] As the management approach

in these 2 disease entities are entirely different, their differentiation carries significant

clinical implication. If the differentiation is difficult clinically, genetic analysis has

been tested to be helpful. It was reported that molecular assay of either oxyR or pncA

gene could be a rapid and useful tool to distinguish BCG lymphadenitis from

tuberculosis. [10]

There are several risk factors for the formation of BCG lymphadenitis. These

can broadly be divided into host related factors and vaccine related factors. The age of

vaccination is closely related to the incidence of BCG lymphadenitis. Vaccine

inoculated in neonatal period carries higher risk. [3] The presence of underlying

immunodeficiency largely increases the risk of severe BCG lymphadenitis. [11] In

fact, genetic defects in the interleukin-12 and interferon-gamma pathway have been

implicated in patients susceptible to mycobacterial cervical lymphadenopathy

secondary to BCG vaccination. [12] Another study demonstrated a significantly lower

level of total lymphocytes, natural killer cells and definite lymphopenia in patients

with BCG lymphadenitis. [13] However, we failed to demonstrate this trend as the

mean white cell count and lymphocyte count in our patients were within normal range

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and there was no case of lymphopenia. Nonetheless, patients with severe, multiple or

recurrent BCG lymphadenitis should have their immune status investigated. Besides

immune competency, clustering of BCG suppurative lymphadenitis has been reported

in family. [14] Although congenital immunodeficiency may partly account the

association, the role of genetic factors in familial susceptibility to mycobacterial

infection needs to be addressed as well. The observed wide discrepancy in the

incidence of BCG lymphadenitis in various countries further supported the role of

genetic predisposition. Vaccine dosage, vaccine strain and vaccine administration

technique have been shown to be related to risk of BCG lymphadenitis. A classical

example was the outbreak of BCG regional lymphadenitis in Gaza in 2001. The surge

of incidence of BCG associated lymphadenitis was found to be related to the

virulence and viability of the Pasteur strain of BCG used and the faulty intradermal

injection technique. [15] The dose-response relationship was nicely demonstrated in a

Germany incident where soar in regional suppurative lymphadenitis cases was noted

after introduction of a new BCG vaccine strain (Copenhagen 1331), and it dropped

significantly after subsequent dose reduction. [16] The identification of such risk

factors plays an important role in early identification of at risk patients and

implementation of preventive measures to lower the risk.

Untreated suppurative lymphadenitis frequently ruptures with sinus formation.

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Healing is mediated through cicatrisation and closure of the sinus. However, it is

associated with an unpleasant and prolonged course of illness, and at risk of scaring

and keloid formation. [5,17] Therefore, suppurative BCG lymphadenitis warrants

medical intervention to hasten recovery and decrease morbidity. Antibiotics like

erythromycin, [18] anti-tuberculous drugs like isoniazid and rifampicin[19] have been

found to be useful in hastening the recovery. However, these studies were

non-randomized and uncontrolled studies. Experts believe that the apparent effect of

erythromycin is probably related to its effect on gram positive cocci, which could

have complicated the infection. In fact, a meta-analysis of 4 randomized controlled

trials showed no significant difference in outcome in usage of erythromycin or

isoniazid. [20] Notwithstanding the side effects of these medications, medical therapy

is not recommended for treatment of BCG lymphadenitis. Complying with medical

evidences, use of anti-tuberculous drugs is no longer a recommended practice in our

locality. The role of needle aspiration in hastening recovery and reducing sinus

formation was verified in randomized controlled trial. As compared to controls, the

regression rate at 2 months and 6 months after presentation were significantly higher

in patients where their lymph nodes were aspirated. The rate of spontaneous drainage

with sinus tract formation was also significantly lower in the aspirated group at 6

months. [21] Needle aspiration also offers opportunity to obtain samples for

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microbiological tests. Repeated needle aspirations were shown to be effective in

patients who failed the initial aspiration attempt. [22] In our study, the duration of

healing was shorter in the aspirated group than non-aspirated group. However, the

difference did not reach a statistical significance probably related to the limited

sample size and power of the study. Surgical excision of whole lymph node was

shown to be effective in shortening the duration of illness. [23] However, the surgical

and anaesthetic risks outweigh its benefits that it should not be regarded as the first

line treatment for suppurative BCG lymphadenitis and generally reserved for cases

who failed repeated needle aspiration attempts, the lymph nodes were multiloculated

or matted, or when draining sinus already established. [7] Incision and drainage is not

recommended as this modality is associated with inadequate clearance of

inflammatory materials, persistent drainage, delayed healing and scarring. [24]

The present study offers an overview of the clinical features and outcomes of

BCG associated suppurative lymphadenitis in our locality which is previously limited.

We found that the median time of onset was 3 months after BCG vaccination and the

mean duration for complete healing was 4.5 months. Solitary palpable mass without

systemic symptom was the universal presentation. The commonest site involved was

ipsilateral axilla region, while supraclavicular lymph nodes were occasionally seen.

Most patients did not have positive smear or culture proof. Previous studies found

22

treatment with needle aspiration significantly shorten recovery time yet other

parameters were not examined. In our study, we explored the relationship between

various clinical parameters and the duration of healing. We demonstrated that sex, age

at presentation, duration since vaccination, lymphocyte count, site and size of lymph

node, presence of spontaneous rupture or sinus formation did not correlate with

duration of healing. On the other hand, we further explored the clinical determinants

for subsequent scarring and found that the size of lymph node at presentation was

significantly associated with scarring, which have not been reported previously.

There are several limitations of the study which warrant comment. This

retrospective study is bound to the inherit shortcomings of missing and incomplete

data. There is also potential measurement and detection bias as there is no standard

criteria in diagnosing BCG associated lymphadenitis and no standardized

measurement method of lymph node and qualification of symptoms and signs.

However, we believe these biases have limited detrimental effects as all cases were

assessed and diagnosed by designated paediatric infectious disease specialists of the

department. Another limitation of our study is the small sample size, which render the

limited power and failure to detect significant correlates of healing duration such as

treatment with needle aspiration. A prospective cohort study involving collaboration

with different centres in Hong Kong can optimize the study and generate higher

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impact results.

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Conclusion

BCG associated suppurative lymphadenitis is not an uncommon complication

of BCG vaccination. The present study described the clinical features, investigations,

treatment and outcomes of suppurative BCG lymphadenitis. The diagnosis is clinical

and should be suspected in children present with ipsilateral regional lymph node

enlargement with history of BCG vaccination, even months afterwards. A basic chest

X-ray is the investigation recommended for all patients while tuberculin skin test has

no diagnostic use. The current study also illustrated the low positive microbiological

yield in aspirate, highlighting that negative smear or culture results do not rule out the

diagnosis. Good immunization technique, correct dosage and cautious use in

immunocompromised hosts are important measures to decrease risk. As evident by

randomized controlled trials, anti-tuberculous treatment has no role in the

management of BCG associated suppurative lymphadenitis, and needle aspiration

remains to be the safe and effective way of treatment. Surgical excision is reserved for

those who failed repeated needle aspiration attempts.

(Word count: 3294)

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14. Banac S, Franulović J. Familial liability to complications after BCG vaccination.

Acta Paediatr. 1997 Aug;86(8):899-902.

15. Daoud W. Control of an outbreak of BCG complications in Gaza. Respirology.

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16. Lehmann HG, Engelhardt H, Freudenstein H, Hennessen W, Widmark R. BCG

vaccination of neonates, infants, schoolchildren and adolescents. Part I: Dose

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19. De Souza GR, Sant'Anna CC, Lapa e Silva JR, Mano DB, Bethlem NM.

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21. Banani SA, Alborzi A. Needle aspiration for suppurative post-BCG adenitis.

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Table 1. Clinical features and outcome of 15 children with BCG associated suppurative lymphadenitis. Case 1 Case 2 Case 3 Case 4 Case 5 Case 6 Case 7 Case 8 Case 9 Case 10 Case 11 Case 12 Case 13 Case 14 Case 15

Age at presentation (months)

2 16 3 5 2 4 26 2 7 2 5 5 3 3 2

Duration after vaccination (months)

2 16 3 5 2 4 26 2 7 2 5 5 3 3 2

Sex M F M M F F M M M F M M M M M WCC 12.4 21.3 8.9 11.4 18.8 10.1 12.5 13.7 14.0 10.7 16.4 6.1 12.3 N/A N/A Lym 8.0 10.8 7.3 4.5 N/A N/A 5.9 5.7 10.0 6.3 11.0 3.3 7.7 N/A N/A Site of LN A S S A A A A S A A A A A A A Size of LN (cm)*

3 1 1.5 1.5 2.5 2.5 3 1 3 3 2 1 3 2 1

AFB smear - + + - - + - + - + + N/A - + N/A M. bovis culture

- - - - - - - + - + - N/A - -

N/A

CXR N N N N N N C N N N N N N N N Mantoux test (mm)

N/A 15 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A

Needle aspiration

+ + + - + + + + + + + - + + -

Spontaneous rupture

+ - - + - - - + - - + - + - -

Sinus formation

- - - - - - - + - - + - - - -

Time to LN resolution (months)

6 6 3 4 N/A N/A 3 5 8 3 5 4 2 3 6

Scarring + - - + N/A N/A + + + + + - + - - A= axillar; AFB = acid fast bacilli; C=calcification at axilla; CXR = chest X-ray; LN = lymph node; Lym = lymphocyte count; N=normal; N/A = not available; S= supraclaviclar; WCC = white cell count * maximal dimension

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Table 2. Comparison of healing time among various clinical parameters

Clinical parameters Healing duration (months) p

Sex (male/female) 4.5±1.8 4.5±2.1 0.97

Site of LN (axilla/supraclavicular) 4.4±1.8 4.7±1.5 0.83

Size of LN (<2cm/≥2cm) 4.3±2.1 4.6±1.2 0.71

Spontaneous rupture (yes/no) 4.4±1.5 4.5±1.9 0.94

Sinus formation (yes/no) 5.0±0.0 4.4±1.8 0.28

Needle aspiration (yes/no) 4.4±1.9 4.8±1.2 0.60