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Chest wall granuloma associated with BCG vaccination presenting as hot abscess in an immunocompetent infant.

Lee HS, Seo KJ, Kim JJ - J Cardiothorac Surg (2015)

Bottom Line: Although it is considered to be a very safe vaccine, sometimes a variety of complications may develop.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.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatrics, Uijeongbu St. Mary's Hospital, The Catholic University of Korea College of Medicine, Uijeongbu, South Korea. iamlidia@catholic.ac.kr.

ABSTRACT
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.

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Chest wall abscess histopathologic findings (A: gross B: microscopic). (A) The mass was a cystic lesion, 3.0 x 1.5 cm in size, filled with yellowish thick fluid. (B) The histopathology revealed a chronic granulomatous inflammation consisting of scattered epithelioid histiocytes, Langhans giant cells (yellow arrow) and areas of caseous necrosis, suggestive of a mycobacterial disease process (H&E stain, x100; inlet x400).
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Fig3: Chest wall abscess histopathologic findings (A: gross B: microscopic). (A) The mass was a cystic lesion, 3.0 x 1.5 cm in size, filled with yellowish thick fluid. (B) The histopathology revealed a chronic granulomatous inflammation consisting of scattered epithelioid histiocytes, Langhans giant cells (yellow arrow) and areas of caseous necrosis, suggestive of a mycobacterial disease process (H&E stain, x100; inlet x400).

Mentions: An 8-month-old Korean female infant presented with a rapidly growing erythematous subcutaneous nodule on the anterior chest wall noted 10 days previously. She had no history of trauma and a complete immunization history. There were no constitutional symptoms, such as fever, chilling, cough, sputum, sweating and weight loss. Seven months ago she was vaccinated in her 4th week of life with intradermal BCG vaccine (Danish strain 1331, Statens Serum Institut, Denmark ) and the vaccination site on her left deltoid healed to leave a scar without any wound complications. A tuberculin skin test was not performed. The physical examination revealed a tender erythematous immobile firm mass along the left second intercostal space of the midclavicular line, measuring about 3 x 2 cm in size (Figure 1). There was no lymphadenopathy or palpable lymph node. The laboratory evaluation demonstrated a WBC count of 12.780 × 103/μL (64% neutrophils, 17% lymphocytes and 19% monocytes), an elevated erythrocyte sedimentation rate (39 mm/hr) and C-reactive protein levels (1.74 mg/dL). Other laboratory investigations including immune study were within normal ranges. Chest X-ray and CT showed a 3 x 2 cm-sized oval subcutaneous mass with soft tissue density without any associated pulmonary parenchymal lesion. On the chest CT, the mass was ill-defined with abscess formation and infiltrated into the surrounding subcutaneous fat and pectoralis major muscle (Figure 2). Under the impression of a chest wall hot abscess or inflamed epidermal cyst, empirical antibiotics were started and an en bloc resection of the mass under general anesthesia was undertaken including the adjacent infiltrated tissue. The mass was a cystic lesion, 3.0 x 1.5 cm in size and filled with yellowish thick fluid. The histopathology revealed a chronic granulomatous inflammation consisting of scattered epithelioid histiocytes, Langhans’ type giant cells and areas of caseous necrosis, suggestive of a mycobacterial disease process (Figure 3). Ziehl Neelsen stain for acid-fast bacteria was negative (Figure 3) and routine cultures of the cystic fluid were all negative for microorganisms including tuberculosis and fungi. The tissue PCR study was also negative for tuberculosis. There was no contact with tuberculosis to the patient in her family or with neighbors. Based on all these findings, diagnosis was made as a BCG vaccine complication, demonstrating with subacute character. Antibiotics were changed to an anti-tuberculosis regimen with isoniazid 15 mg/kg/day lasting for 6 months and the patient was in a good healthy status without any complications until 1 year of age on follow-up.Figure 1


Chest wall granuloma associated with BCG vaccination presenting as hot abscess in an immunocompetent infant.

Lee HS, Seo KJ, Kim JJ - J Cardiothorac Surg (2015)

Chest wall abscess histopathologic findings (A: gross B: microscopic). (A) The mass was a cystic lesion, 3.0 x 1.5 cm in size, filled with yellowish thick fluid. (B) The histopathology revealed a chronic granulomatous inflammation consisting of scattered epithelioid histiocytes, Langhans giant cells (yellow arrow) and areas of caseous necrosis, suggestive of a mycobacterial disease process (H&E stain, x100; inlet x400).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4352557&req=5

Fig3: Chest wall abscess histopathologic findings (A: gross B: microscopic). (A) The mass was a cystic lesion, 3.0 x 1.5 cm in size, filled with yellowish thick fluid. (B) The histopathology revealed a chronic granulomatous inflammation consisting of scattered epithelioid histiocytes, Langhans giant cells (yellow arrow) and areas of caseous necrosis, suggestive of a mycobacterial disease process (H&E stain, x100; inlet x400).
Mentions: An 8-month-old Korean female infant presented with a rapidly growing erythematous subcutaneous nodule on the anterior chest wall noted 10 days previously. She had no history of trauma and a complete immunization history. There were no constitutional symptoms, such as fever, chilling, cough, sputum, sweating and weight loss. Seven months ago she was vaccinated in her 4th week of life with intradermal BCG vaccine (Danish strain 1331, Statens Serum Institut, Denmark ) and the vaccination site on her left deltoid healed to leave a scar without any wound complications. A tuberculin skin test was not performed. The physical examination revealed a tender erythematous immobile firm mass along the left second intercostal space of the midclavicular line, measuring about 3 x 2 cm in size (Figure 1). There was no lymphadenopathy or palpable lymph node. The laboratory evaluation demonstrated a WBC count of 12.780 × 103/μL (64% neutrophils, 17% lymphocytes and 19% monocytes), an elevated erythrocyte sedimentation rate (39 mm/hr) and C-reactive protein levels (1.74 mg/dL). Other laboratory investigations including immune study were within normal ranges. Chest X-ray and CT showed a 3 x 2 cm-sized oval subcutaneous mass with soft tissue density without any associated pulmonary parenchymal lesion. On the chest CT, the mass was ill-defined with abscess formation and infiltrated into the surrounding subcutaneous fat and pectoralis major muscle (Figure 2). Under the impression of a chest wall hot abscess or inflamed epidermal cyst, empirical antibiotics were started and an en bloc resection of the mass under general anesthesia was undertaken including the adjacent infiltrated tissue. The mass was a cystic lesion, 3.0 x 1.5 cm in size and filled with yellowish thick fluid. The histopathology revealed a chronic granulomatous inflammation consisting of scattered epithelioid histiocytes, Langhans’ type giant cells and areas of caseous necrosis, suggestive of a mycobacterial disease process (Figure 3). Ziehl Neelsen stain for acid-fast bacteria was negative (Figure 3) and routine cultures of the cystic fluid were all negative for microorganisms including tuberculosis and fungi. The tissue PCR study was also negative for tuberculosis. There was no contact with tuberculosis to the patient in her family or with neighbors. Based on all these findings, diagnosis was made as a BCG vaccine complication, demonstrating with subacute character. Antibiotics were changed to an anti-tuberculosis regimen with isoniazid 15 mg/kg/day lasting for 6 months and the patient was in a good healthy status without any complications until 1 year of age on follow-up.Figure 1

Bottom Line: Although it is considered to be a very safe vaccine, sometimes a variety of complications may develop.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.

View Article: PubMed Central - PubMed

Affiliation: Department of Pediatrics, Uijeongbu St. Mary's Hospital, The Catholic University of Korea College of Medicine, Uijeongbu, South Korea. iamlidia@catholic.ac.kr.

ABSTRACT
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.

Show MeSH
Related in: MedlinePlus