Mycobacterium bovis osteomyelitis as a complication of Bacille Calmette-Guérin (BCG) vaccination: rapid diagnosis with use of DNA sequencing analysis: a case report

Chest Wall Mass in Infancy: The Presentation of Bone-Tumor-Like BCG Osteitis

Chest wall mass in infancy is rare. Malignant lesions are more common than infection or benign tumors. This is a case of a 12-month-old girl who presented with a 2 cm mass at the right costal margin and poor weight gain. Chest radiograph demonstrated a moth-eaten osteolytic lesion at the 8th rib. The resection was performed, and a mass with pus content was found. The positive acid fast stain (AFB) organism was noted. Pathology confirmed caseous granulomatous inflammation compatible with mycobacterial infection. However, QuantiFERON-TB Gold was negative, so Mycobacterium bovis (M. bovis) osteitis is highly suspected. She was treated with antimycobacterium drugs and showed good results. Osteomyelitis can manifest by mimicking bone tumors. Without a biopsy, the pathogen may go undetected. So, interventions such as biopsy are warranted and avoid mass resection without indication. High C-reactive protein (CRP), alkaline phosphatase (ALP), periosteal reaction of radiating spicules, and penumbra sign in magnetic resonance imaging (MRI) are helpful for discriminating osteomyelitis from bone tumor.

Bacille Calmette-Guérin Vaccine-Induced Tuberculous Hip Osteomyelitis in an Infant: Case report

To this day, tuberculosis (TB) continues to pose a significant global health burden. The World Health Organization's Expanded Programme on Immunization (EPI) recommends the bacille Calmette-Guérin (BCG) vaccine for infants to protect against the haematogenous spread of primary TB and other more severe types of TB infection. We report an eight-month-old boy who presented to the Armed Forces Hospital, Muscat, Oman, in 2015 with a one-month history of intermittent fever associated with a limited range of motion in the right hip area. He was up-to-date with his EPI vaccinations and had no history of exposure to individuals with TB infections. He was initially treated for bacterial septic arthritis; however, a GeneXpert TB assay revealed the presence of Mycobacterium tuberculosis, BCG strain. To the best of the authors' knowledge, this is the first documented case from Oman of a child with TB hip osteomyelitis due to a BCG vaccination.

Recurrent Bacille Calmette-Guérin osteomyelitis with ankle joint involvement in a toddler: gait analysis and rehabilitation experience

Bacille Calmette-Guérin (BCG) osteomyelitis is a rare complication after vaccination. This article reports on a 1-year-old immunocompetent boy with recurrent BCG osteomyelitis involving the distal tibia who presented with a limping gait from the beginning of toddling. The lesion was located in the metaphysis and crossed the growth plate to the epiphysis, causing concern for ambulation. After surgery, he was initiated on an individualized, intense rehabilitation program and achieved a good functional recovery. Rehabilitation programs with gait analyses provide effective therapeutic and monitoring methods for toddlers recovering from BCG osteomyelitis.

[BCG multifocal osteomyelitis. A case report]

Multifocal osteomyelitis is a rare complication of the Bacille Calmette-Guerin (BCG) vaccine. It particularly affects immunocompromised children and poses a difficult diagnostic problem. A 6-month-old boy had BCG vaccination postnatally and developed extensive disseminated skeletal osteomyelitis. He was found to have severe combined immunodeficiency. Despite antibiotic therapy and bone marrow grafting, the disease was fatal.

A localised soft tissue and bone enlargement in an infant mandible

A 4-month-old infant was referred by a paediatrician for a rapidly growing swelling on the right side of the mandible of 1.5 months duration. His medical and family history was unremarkable. Palpation divulged a firm and tender enlargement with the overlying soft tissue showing no significant alteration in colour. CT scan revealed cortical irregularity involving the ramus on the right side along with right masseter muscle hypertrophy. Routine haematological investigation yielded values within normal limits except for a raised erythrocyte sedimentation rate. Histopathological examination of the tissue submitted following an open biopsy procedure showed reactive lamellar bone and trabeculae with fibrous marrow exhibiting inflammation. The final diagnosis of infantile cortical hyperostosis was clinched based on the clinicopathological correlation. A rare reactive bone dystrophy which could pose a certain diagnostic dilemma is addressed herewith.

Surgical treatment of an infant with Bacille Calmette-Guérin osteomyelitis extending across the growth plate

Bacille Calmette-Guérin osteomyelitis in infants is a known complication of Bacille Calmette-Guérin vaccination. Treatment consists of antituberculosis chemotherapy after biopsy/curettage; however, in cases of Bacille Calmette-Guérin osteomyelitis extending to the growth plate and epiphysis, the extent and time of surgical treatment such as curettage/biopsy is unknown because of bone growth disturbances. This article presents a case of an infant with this type of Bacille Calmette-Guérin osteomyelitis at the proximal tibia. A metaanalytic review was performed for possible risk factors of its recurrence. In our patient, primary curettage of partial lesion, excluding the part extending to the growth plate and epiphysis, failed, and recurettage of the extended lesion involving the growth plate and epiphysis was required for its eradication, resulting in bone growth disturbance. In the metaanalysis, 7 literatures reporting 14 cases of Bacille Calmette-Guérin osteomyelitis extending to the growth plate and epiphysis were included. Although statistical analysis showed no significant risk factors associated with the recurrence, these cases showed high recurrence rate in approximately 55.6%, requiring reoperation. Generally, the smaller damage to the growth plate can minimize bone growth disturbance. Taken together, it is suggested that Bacille Calmette-Guérin osteomyelitis extending to the growth plate and epiphysis is associated with high recurrence rate, and early curettage of the entire lesion should be performed to eradicate it and avoid resulting complications.

Osteitis after BCG vaccination

The authors report the case of a 21-month-old boy with an osteolytic lesion in the proximal region of the right humerus. Based on the clinical history and histological findings, the authors suspected osteitis following BCG vaccination. Symptoms remitted after antituberculosis therapy was initiated, and the patient presented radiological improvement. The authors describe this uncommon entity in pediatric practice and call attention to possible complications of BCG vaccination.

Refractory osteomyelitis caused by bacille Calmette-Guérin vaccination: a case report

A male infant, 1 and a half years old, was affected with bacille Calmette-Guérin osteomyelitis of the left tibia. The gyrB DNA direct sequencing, followed by restriction fragment length polymorphism of genomic DNA from a biopsy sample of the lesion, made diagnosis rapid.

Immunologic response enhances atherosclerosis-type 1 helper T cell (Th1)-to-type 2 helper T cell (Th2) shift and calcified atherosclerosis in Bacillus Calmette-Guerin (BCG)-treated apolipoprotein E-knockout (apo E-/-) mice

Although immunocompetent hosts develop protective type 1 helper T cell (Th1) responses in mycobacterial infections, seroepidemiologic studies show that patients with atherosclerosis commonly express high antibody titers against mycobacterial heat shock protein (HSP) 65 and may develop a nonprotective type 2 helper T cell (Th2) response and advanced disease. These studies were undertaken to define mycobacterial dose requirements and kinetics for development of antibodies to HSP65, the Th1 to Th2 shift of immune response, and calcified atherosclerotic lesion development in the apo E-/- mouse. Fourteen-week apo E-/- female mice were treated intraperitoneally (ip) with heat-killed M. bovis Bacillus Calmette-Guerin (BCG), and 14 days later, cross-sections from the ascending aortas were stained for measurement of lesion size and calcium deposition. At 14 days, 0.01-mg BCG induced Th1 responses against HSP65. In contrast, 1-mg BCG induced splenic PGE2-releasing macrophages with a Th1-to-Th2 shift of responses to HSP65, which was PGE2-dependent. Treatment with 1-mg BCG significantly lowered bone density with increases in marrow osteoclastogenesis and development of calcified lesions in the aorta. At 14 days, 0.01-mg BCG induced Th1-dependent HSP65 responses and did not advance atherosclerosis. In contrast, for 1-mg BCG, a PGE2-dependent Th1-to-Th2 shift of responses to HSP65 and evidence of bone resorption are associated with advanced calcified atherosclerotic lesions.

Osteoarticular side effects of BCG therapy

Although osteoarticular side effects of the Bacillus Calmette-Guérin (BCG) are rare compared to the number of administrations, BCG vaccination and cancer therapy are so widely used that the absolute number of cases is not negligible. Osteoarticular infection is an exceedingly rare complication of vaccination with the BCG. Intravesical BCG instillations used to treat superficial bladder cancer may cause arthralgia, reactive arthritis or osteoarticular infections. Intradermal BCG therapy used to treat a number of malignancies can cause osteoarticular infections or bilateral symmetric polyarthritis predominating in the wrists and fingers. In practice, when intravesical BCG instillation is followed by arthritis, hyperthermia is unhelpful for distinguishing septic arthritis from reactive arthritis. Arguments pointing to reactive arthritis include oligo- or polyarticular involvement and onset a few weeks (as opposed to a few months) after the last instillation. Nevertheless, joint fluid examination is in order to rule out septic arthritis. BCG-induced reactive arthritis usually responds well to nonsteroidal anti-inflammatory drugs. Osteoarticular infections related to BCG therapy should be treated by rifampin, isoniazid and ethambutol for 2 months, followed by rifampin and isoniazid for 10 months.

Epstein-Barr virus associated with primary CNS lymphoma and disseminated BCG infection in a child with AIDS

BACKGROUND

AIDS patients are at increased risk of developing concurrent infections with viral, parasitic, fungal or mycobacterial organisms. They can present constitutional symptoms of fever and weight loss, either due to infections or an underlying lymphoma which may coexist.

CASE REPORT

A child with HIV-AIDS and mild encephalopathy is reported, who during the course of a confirmed disseminated mycobacterial disease developed neurological impairment. Post-mortem examination revealed disseminated BCG infection and Epstein-Barr associated primary CNS lymphoma. Epstein-Barr virus (EBV) presence was assessed by LMP-1 protein labelling by immunohistochemistry and in situ hybridisation (ISH) for Epstein-Barr virus-encoded RNAs (EBERs) in formalin-fixed and paraffin-embedded sections.

CONCLUSIONS

BCG vaccination among HIV-1 infected children leads to the risk of disseminated BCG infection. BCG immunization programmes should be reconsidered for children at risk of HIV infection, because the risk of delayed complications is independent of the immunological status at the time of the vaccination. Only isolated cases of primary CNS lymphoma occurring in HIV-infected children have been reported, and a striking association with EBV infection has been demonstrated.

Calmette-Guérin bacillus sternal osteomyelitis diagnosed by DNA sequencing analysis of PNC A

Sternal osteomyelitis is an uncommon complication of Calmette-Guérin bacillus vaccination. Herein we describe a 4-month-old Taiwanese infant with a growing parasternal mass resulting from sternal osteomyelitis. By using DNA sequencing analysis, we identified the etiology as Calmette-Guérin bacillus vaccination.

Infection-induced up-regulation of the costimulatory molecule 4-1BB in osteoblastic cells and its inhibitory effect on M-CSF/RANKL-induced in vitro osteoclastogenesis

Bacterial infection sometimes impairs bone metabolism. In this study, we infected the osteoblastic cell line MC3T3-E1 with Mycobacterium bovis bacillus Calmette-Guérin (BCG) and identified genes that were up-regulated in the BCG-infected cells by the suppression subtractive hybridization method. A gene encoding 4-1BB (CD137), a member of the tumor necrosis factor-alpha receptor family, was found to be one of the up-regulated genes. Up-regulation of 4-1BB was also observed by infection with Escherichia coli, Salmonella typhimurium, and Staphylococcus aureus, and by treatment with lipopolysaccharides and heat-killed BCG. Bone marrow cells and the macrophage-like cell lines J774 and RAW264.7 were found to express 4-1BB ligand (4-1BBL). Recombinant 4-1BB (r4-1BB) that was immobilized on culture plates strongly inhibited macrophage colony stimulating factor (M-CSF)/receptor activator of nuclear factor-kappaB ligand (RANKL)-induced in vitro osteoclast formation from bone marrow cells. Anti-4-1BBL antibody also inhibited osteoclast formation to a lesser extent, indicating involvement of reverse signaling through 4-1BBL during inhibition of osteoclast formation. A casein kinase I (CKI) inhibitor markedly suppressed the inhibitory effect of r4-1BB on M-CSF/RANKL-induced osteoclast formation, suggesting that CKI might be involved in 4-1BB/4-1BBL reverse signaling. r4-1BB showed no effects on M-CSF- or RANKL-induced phosphorylation of I-kappaB, ERK1/2, p38, or JNK, whereas RANKL-induced phosphorylation of Akt, a downstream target of phosphatidylinositol 3-kinase (PI3K), was completely abolished by r4-1BB, suggesting that 4-1BB/4-1BBL reverse signaling may interfere with PI3K/Akt pathway. r4-1BB also abolished RANKL-mediated induction of nuclear factor of activated T cells-2. This study may elucidate a novel role of 4-1BB in cell metabolism, especially osteoclastogenesis.

Erythema induratum associated with tuberculous lymphadenitis: analysis of a case using polymerase chain reactions with different primer pairs to differentiate bacille Calmette-Guérin (BCG) from virulent strains of Mycobacterium tuberculosis complex

We retrospectively analyzed a bacille Calmette-Guérin (BCG) vaccinated female patient who developed erythema induratum in association with tuberculous lymphadenitis. The polymerase chain reaction (PCR) with two pairs of primers was performed. Only one pair was able to detect the myocobacterial DNA from the paraffin-embedded specimen of the erythema induratum (EI) lesion. However, both pairs showed positive results with the tuberculous lymphadenitis specimen. Sequence analysis of the PCR products excluded the possibility of BCG as the potential pathogen. Both lesions responded favorably to antituberculous therapy. Our study attests to the tuberculous nature of EI and demonstrates that BCG vaccination per se does not induce the lesion or interfere with the PCR result. Finally, using at least two pairs of primers targeting different genomic segments and possessing species-identification capability may raise the detection rates and solve some controversies about the nature of tuberculids.