BCG LYMPHADENITIS IN AN HIV-INFECTED CHILD 9.5 YEARS AFTER VACCINATION

Complications of Bacillus Calmette-Guerin (BCG) vaccination have been reported in immunocompetent as well as in immunocompromised individual s. Severe and/or late complications have been associated with impairme nt of cell-mediated immunity. A case of BCG lymphadenitis in a vertica lly infected HIV-positive boy 9.5 years after vaccination is presented . The vaccination was performed within the first week of life, the HIV status of the mother being unknown. When the boy was 2.5 years old, h is HIV infection was diagnosed after his mother had died from AIDS. At that time his CD4 count was 739 cells/mu L. In the course of the foll owing years, his CD4 count declined steadily, until it reached a low o f about 20 cells/mu L at the age of 5.5 years. He was troubled with re curring respiratory infections and one incidence of severe pancreatiti s. Apart from that, he was in stable condition and led a more or less normal life. At the age of 9.5 years he developed lymphadenitis in his left axilla. The node was examined via biopsy, and the appropriate te sts showed an infection with Mycobacterium bovis BCG variety. The CD4 count at that time was 16 cells/mu L, polymerase chain reaction showed 220,000 RNA copies/mL. There were no signs of dissemination. Antitube rcular agents were administered, and an antiretroviral combination the rapy was started. The patient was discharged from the hospital after a pproximately 2 months. After an uneventful period of 9 months, the boy , still on antitubercular medicine, exhibited a secreting fistula in h is left axilla, again due to Mycobacterium bovis, BCG variety. The fis tulous tissue was removed surgically, and the antitubercular treatment was given intravenously for almost 3 months before being changed to a n oral application. In addition, the antiretroviral regimen was comple tely exchanged. The case presented illustrates that there is a risk of very late complications in HIV-infected individuals, even when they a re vaccinated when they are asymptomatic newborns. Although the risk s eems low, one has to be aware of the problem because timely treatment is probably essential to prevent dissemination of the infection. Late complications of BCG vaccinations are most likely to be detected in co untries with high medical standards, where HIV-infected children are s urviving for longer periods of time.