BCG lymphadenitis: a potential complication of immune reconstitution following haematopoietic stem cell transplant

An MHC class II deficient 2-year-old boy presented with fever and an enlarging left neck mass 100 days post allogeneic haematopoietic stem cell transplant (HSCT). Fever persisted despite treatment with broad-spectrum β-lactam antibiotics. His BCG vaccination site at presentation was quiescent. Ultrasound showed enlarged cervical lymph nodes. An incisional biopsy of the large nodal mass yielded acid-fast bacilli, identified as Mycobacterium bovis by genome sequencing. Treatment with rifampicin, isoniazid and pyridoxine was started. The mass suppurated (figure 1), before healing concurrently with T-lymphocyte reconstitution at approximately day 130 post-HSCT.

Hypophysitis and other autoimmune complications related to immune checkpoints inhibitors´ treatment: Spectrum of imaging appearances

OBJECTIVES

Immune checkpoints inhibitors (ICI) represent a new therapy option for the treatment of several advanced tumors. However, this therapy has been linked to a spectrum of ICI related autoimmune (AI) adverse events. Some may be life threatening and their diagnosis is tricky. The aim of our study was to describe various imaging appearances of ICI related secondary hypophysitis and other coincidental AI diseases.

MATERIAL AND METHODS

We included 28 patients (19 females, 9 men, mean aged 58±13 years), who were consecutively treated mostly for advanced stage melanoma by different ICI. All their CT/MRI records and clinical data were reviewed.

RESULTS

We found 5 (18%) cases of endocrinology proven secondary hypophysitis; 2 cases of panhypopituitarism and 3 cases of central hypocortisolism. Four cases were MRI positive, 1 case was MRI negative. Three cases were accompanied by other AI diseases: 1 by hemorrhagic colitis and mesenterial lymphadenitis, 1 by AI pancreatitis and 1 by pneumonitis. On MRI pituitary gland was swollen in 3 cases, twice enhanced non-homogenously, once homogenously; infundibular enlargement was present in 2 cases. Those 3 cases reacted to glucocorticoid therapy by hypophyseal shrinkage. In 1 case of MRI positive hypophysitis, the pituitary gland was not enlarged, slightly nonhomogeneous with peripheral contour enhancement; no reaction to glucocorticoids was mentioned.

CONCLUSION

Secondary hypophysitis is probably more common ICI related adverse event than reported in the literature. Its MRI appearance is variable. Most of our cases were in coincidence with other AI ICI related events that affected their clinical manifestations.

Role of needle aspiration and surgical excision in management of suppurative Bacillus Calmette Guerin lymphadenitis

The aim was to determine the role of needle aspiration and surgical excision in the management of suppurative Bacillus Calmette Guerin (BCG) lymphadenitis. This prospective study was done in Rafha Central Hospital, over 1.5 years. Thirty two patients were enrolled after informed consent. Needle aspiration was done if size of lymphadenitis was up to 3cm. Surgical excision was done primarily for size more than 3cm or in cases of failed aspiration. Eighteen were males and 14 were females. Median age was 3.75 months (IQR 2-7). All were full term with normal birth weight and vaccinated in first 2 days of life. Predominantly single region of lymphadenitis was involved in 75% cases; with left axilla being mainly affected (56.3% cases). Needle aspiration was done in 18 cases and surgical excision was carried out in 14 cases. Resolution of lymphadenopathy was 7 days in cases of surgical excision, while within 60 days in cases of aspiration. Failure of aspiration was noted in cases of multiple, matted suppurative lymph nodes.

Inherited IL-12Rβ1 Deficiency in a Child With BCG Adenitis and Oral Candidiasis: A Case Report

Tuberculosis is a major worldwide problem, and protection from it is achieved mainly by live attenuated bacille Calmette-Guérin vaccine, which is capable of causing disease in immunocompromised host. Oral thrush is abnormal in healthy children, which suggests an underlying immunodeficiency. Mendelian susceptibility to mycobacterial disease is a rare primary immunodeficiency characterized by a selective predisposition to weakly virulent Mycobacteria and Salmonella and also predisposition to chronic mucocutaneous candidiasis. Interleukin 12 receptor β1 (IL-12Rβ1) deficiency is the most common disease of Mendelian susceptibility to mycobacterial disease, and to date only 50 IL-12Rβ1 deficient patients with clinical signs of chronic mucocutaneous candidiasis have been reported. We report a 2.5-year-old daughter of consanguineous parents with both regional bacille Calmette-Guérin lymphadenitis and recurrent oral candidiasis carrying biallelic R175W mutation in the IL12RB1 gene, resulting in complete loss of expression of IL-12Rβ1. To our knowledge, this is the first report of bacille Calmette-Guérin lymphadenitis with concurrent oral candidiasis displaying such a mutation. New mutations and wide clinical diversities are the indisputable fact of populations with a high rate of consanguineous marriages.

Contralateral intramammary silicone lymphadenitis in a patient with an intact standard dual-lumen breast implant in the opposite reconstructed breast

Silicone lymphadenopathy is a recognized complication of silicone gel implant rupture; the ipsilateral axillary lymph nodes are most commonly involved. We report imaging findings on a range of different imaging modalities and biopsy results in a case of biopsy-proven silicone lymphadenitis involving contralateral intramammary and axillary lymph nodes in a patient with an intact standard dual-lumen breast implant in the opposite reconstructed breast. This case demonstrates that in a patient with disrupted lymph drainage due to prior mastectomy and axillary node dissection for breast cancer treatment, silicone particles can migrate in a retrograde fashion via the ipsilateral internal mammary lymph nodes and reach not only the contralateral axilla but also the outer quadrants of the contralateral breast, even in the presence of an intact breast implant.

[The role of immunodeficiencies in development of complications during vaccination of children with BCG vaccine]

AIM

Study of the interrelation between the presence of immune deficiency and development of complications during vaccination of newborns with BCG vaccine.

MATERIALS AND METHODS

In 24 children with complications of vaccine process in the form of cold abscess and lymphadenitis indicators of lymphocyte subpopulation levels were studied by flow cytofluorimetry on Beckman Coulter cytofluoriemter by using monoclonal antibodies with markers CD45+CD3+ - T-cell, CD45+CD3+CD4+ - T-helpers, CD45+CD3+CD8+ - T-supressors-cytotoxic killers, CD45+CD3 CD16+CD56+ - natural killers, CD45+CD3-CD19+ - B-lymphocytes. The level of IgG, IgA, IgM in sera was determined by immune diffusion method in agar by Mancini.

RESULTS

In 4 children selective deficiency of IgA, in 5 - hyper-IgM syndrome was detected, which is an innate immunodeficiency and is characterized by the lack of sera IgA, reduction of IgG level and increase of IgM. In 9 children a reduction of CD16+ natural killer lymphocytes was detected, in some cases combined with a reduction of CD8+ T-supressors-cytotoxic killers.

CONCLUSION

The reason of development of complications during BCG administration is the presence of immunodeficiency in children. In these children severe course of the vaccine process, presence of axillary lymphadenitis was observed, therapy of these children continued from 4 to 6 months.

Safety of intradermal Bacillus Calmette-Guerin vaccine for neonates in Eastern Saudi Arabia

OBJECTIVE

To evaluate the safety of Bacillus Calmette-Guerin (BCG) in Saudi infants and outline our management for BCG related lymphadenitis.

METHODS

The records of infants who developed BCG related complications were retrospectively reviewed from March 2008 to March 2011 at the Maternity and Children Hospital, Dammam, Saudi Arabia for age, gender, birth weight, presentation, and outcome. All our patients were immunized with the BCG vaccine within 48 hours after birth, and the total number of vaccinated newborns was obtained from the vaccination registry.

RESULTS

During a 3-year period (March 2008 to March 2011), 26,000 newborns received BCG and 81 (51 males and 30 females) developed complications. This gives an incidence of 3.12 complications/1000 newborns. Their presentations were: left axillary lymphadenitis (n=62), supraclavicular lymphadenitis (n=9), collection at immunization site (n=6), and one each (left cervical lymphadenitis, bilateral axillary lymphadenitis, left arm abscess, left axillary lymphadenitis and collection at immunization site). Two were immunocompromized and 6 with local collection were aspirated. The arm abscess had drainage. Simple lymphadenitis (n=6) were treated expectantly, while those with suppurative lymphadenitis (n=68) had excision (n=65) or incision and drainage (n=3) without anti-tuberculous treatment.

CONCLUSION

Bacillus Calmette-Guerin is safe but is associated with a relatively high incidence of suppurative lymphadenitis. Non-suppurative lymphadenitis can be treated conservatively, while suppurative lymphadenitis should be treated with excision. This is safe, avoids rupture, and shortens the recovery period without anti-tuberculous treatment. Although, the use of BCG vaccine may be associated with side effects, the potential morbidity and mortality from tuberculosis outweighs that from BCG related complications.

Surveillance of adverse events following immunization: 10 years' experience in Oman

A descriptive record-based review of adverse events following immunization (AEFI) was carried out in Oman using the national database for the period 1996-2005. A total of 790 adverse event reports were received with an annual rate during the review period of 33.7 per 100 000 population or 10.8 per 100 000 doses administered. There were no reported deaths. The most frequently reported AEFI were BCG adenitis (69.7 per 100 000 doses) and local reactions (3.6 per 100 000 doses respectively). The statistically significant higher rates among males, in children aged > 2 years and in some sparsely populated regions of Oman need further research. AEFI rates in Oman were similar or below the international averages

Bacille Calmette-Guérin lymphadenitis and immune reconstitution syndrome in HIV-infected children on antiretroviral therapy in Jamaica

The immune reconstitution inflammatory syndrome (IRIS) is a recognized complication associated with opportunistic infections occurring in HIV-infected individuals after the initiation of highly active antiretroviral therapy (HAART). We report on three HIV-infected infants with rapid progressor HIV disease who present with IRIS due to the BCG vaccine and occurring 3-6 weeks after initiation of HAART

Tuberculosis complicating treatment of hepatitis C in an HIV-infected haemophilia A patient

Pegylated interferon (pegIFN)/ribavirin has been established as the treatment of choice for chronic hepatitis C in HIV co-infected individuals [1-3]. We report the case of an individual who was well prior to treatment, but was diagnosed with tuberculous adenitis after receiving 12 weeks of pegIFN/ribavirin therapy. The association of pegIFN and ribavirin therapy with tuberculosis (TB) has not been described previously.

Complications associated with the bacille Calmette-Guérin vaccination in Ireland

INTRODUCTION

BCG vaccination is currently recommended for all newborns in Ireland except where specifically contraindicated. This paper describes a marked increase in the number of referrals of patients with localised complications after vaccination to two Dublin paediatric hospitals. This increase coincided with the introduction of a new strain of BCG vaccine

METHODS

A population surveillance study was undertaken to determine the frequency and spectrum of complications associated with the new strain of BCG vaccine introduced in Ireland. Patients were identified though review of the infectious disease service case records and microbiology laboratory culture reports for the two year period from August 2002 to July 2004. Prospectively gathered data were supplemented by retrospective chart review. All infants who had inoculation site abscesses, suppurative adenopathy, or non-suppurative adenopathy with nodes > or =2 cm were included.

RESULTS

Fifty eight patients presented a median of 13 weeks post-inoculation: 32 with suppurative adenitis, 17 with inoculation site abscess, three with both inoculation site abscess and suppurative adenitis, and six with non-suppurative adenopathy. The overall complication rate was estimated at 1/931 vaccinees with 1/1543 developing suppurative adenitis. Twenty six infants required surgery.

DISCUSSION

This series illustrates the role of hospitals in sentinel surveillance and highlights the importance of having a well functioning and responsive system of adverse event reporting. These events raise a serious question as to the suitability of this vaccine strain for use in a national immunisation programme in a country where the prevalence of tuberculous disease is 10.4/100,000.

[Clinical studies of vaccine TEOVac under the conditions of remote revaccination]

In the clinical trials of vaccine TEOVac in lower and reglamented doses under the conditions of remote vaccination, carried out on 11 volunteers, local reactions in the form of hyperemia, gingival edema (1 vaccinee), faucial hyperemia, enlargement of submaxillary lymph nodes (2 vaccinees) were registered in some of the vaccines; in one vaccinee systemic postvaccinal reaction of medium gravity was observed. Revaccination produced no negative effect on the hematological and biochemical characteristics of the blood, as well as on the urine characteristics. The study of the sensitizing vaccine to the antigens of the accumulation substrate (chick embryo), as well as its influence on the development of autoimmune reactions, revealed the absence of the allergic action of the preparation and its influence on autoimmune processes in the vaccines. The trial of the smallpox vaccine in tablets under the conditions of the primary immunization of adults was the topical and most promising trend in the improvement of smallpox vaccination, as the preparation TEOVac proved to be safe, in contrast to the traditional smallpox vaccine introduced by the scarification method, for both vaccines and nonimmunized persons having contacts with them.

Bacillus Calmette-Guerin (BCG) lymphadenitis-changing trends and management

BACKGROUND

Bacillus Calmette-Guérin (BCG) vaccination is performed as a part of expanded Programme of Immunization (EPI). Suppurative lymphadenitis is the common complication of BCG vaccination. The optimum treatment for this complication is debated.

METHODS

All cases of BCG lymphadenitis presenting to pediatric surgical service over a 17-year study period were reviewed to determine the optimum treatment for this problem.

RESULTS

Sixty children were referred for the management of BCG lymphadenitis during the study period. Most patients (n=43) presented during 1988 and 1990. Children were healthy and received BCG (Pasteur strain) vaccination at EPI during first 2 months of life. Initially all the patients received medical treatment with anti-tuberculous drugs for one to nine months. Fifty-two children who presented with large (approximately 3cm) fluctuant lymph nodes, required a surgical procedure to avoid spontaneous rapture and sinus formation (Group A), whereas medical treatment was effective in five out of eight patients presenting with small (approximately 1 cm) nodes (Group B).

CONCLUSIONS

Medical treatment with antituberculous drugs is not effective to treat BCG lymphadenitis, when the involved lymph nodes are around 3.0 cm and have developed fluctuation and inflammation of over lying skin.

Reactions and their management

The uneventful response to chemotherapy in leprosy is marked by clinically disturbing episodes encountered in 20-30% of patients and these phenomena are called "reactions". Generally they are classified as reversal reaction (type-1) and erythema nodosum leprosum (type-2). The cutaneous menifestations are: (1) Type-2 reactions in LL, BL types constituting erythema nodosum leprosum, erythema multiforme, erythema necroticans, subcutaneous nodules, lepromatous exacerbation. (2) Type-1 reactions in borderline and tuberculoid leprosy. The other manifestations include: Acute neuritis, lymphadenitis, arthritis, oedema of the hands and feet, ocular lesions, etc. Sequelae of reactions are: Paralytic deformities, non-paralytic deformities, extensive scarring and renal damage. A simple guideline to identify the risk-prone cases has been narrated. Prednisolone in standard dosage schedule as recommended by WHO is now being widely used in control programmes.

[Inguinal silicotic adenopathy: presentation of a case]

Silicosis is a sistemic occupational disease, including in the group of pneumoconiosis, because is resulting from the inhalation of microscopic particles of crystalline silica, which deposition and histologic changes take place in lung tissue. A 30 year-old male, construction worker who presented many mediastinal, abdominal and groinal adenopathies without lung damaged. A groinal adenophaty biopsy showed the presence of numerous noncaseating granulomas containing scattered polarizable particles compatible with silica. This case has the particular feature of the exclusive extrapulmonary presentation of silicosis.

Rates of adverse reactions to first and second doses of BCG vaccination: results of a large community trial in Brazilian schoolchildren

OBJECTIVE

To evaluate the incidence of adverse reactions to first and second bacille Calmette-Guérin (BCG) vaccination in schoolchildren.

SETTING AND DESIGN

Enhanced surveillance in a Brazilian trial. Suspected reactions were reported to a nurse who visited cases and completed a standard form.

RESULTS

Among 71341 schoolchildren studied, 33 reactions were reported. Of these, 25 fulfilled the criteria, resulting in a rate of one per 2854 vaccinations, with no deaths or BCG-osis. Reactions to second doses were more common than to first BCG vaccinations, but this difference was not statistically significant.

CONCLUSIONS

Adverse reactions to a second dose of BCG may be more frequent than reactions to a first dose, but they are still rare events.

O-(2-[(18)F]Fluoroethyl)- L-tyrosine (FET): a tracer for differentiation of tumour from inflammation in murine lymph nodes

High uptake of [(18)F]fluoro-2-deoxy- D-glucose (FDG) by inflammatory cells is a frequent cause of false positive results in lymph node (LN) staging by positron emission tomography. Previous studies suggest that radiolabelled amino acids may be more specific markers for viable tumour tissue than FDG. The aim of this study was to investigate quantitatively the uptake of FDG, [(3)H]methyl- L-methionine (MET) and O-2-([(18)F]fluoroethyl)- L-tyrosine (FET) in tumour-infiltrated and immunologically stimulated LNs. Popliteal LNs of Balb/c and DBA/2 mice were stimulated by injection into the right posterior foot pad of mice of either streptozotocin (STZ), causing chronic lymphadenitis, or concanavalin A (Con A), resulting in acute lymphadenitis. Tumour-infiltrated popliteal LNs were induced by inoculation of 2x10(5) lacZ-tagged T cell mouse lymphoma cells into the right posterior foot pad of syngeneic mice. Twenty-one days post inoculation of tumour cells or at various time points after STZ or Con A injection, mice were simultaneously injected intravenously with MET and FDG or MET and FET. After 30 min, mice were sacrificed and tracer uptake was determined in popliteal LNs. Contralateral LNs and LNs of untreated mice served as controls. Histopathological and immunohistochemical analysis demonstrated typical signs of chronic inflammation (non-specific sinus hyperplasia with macrophages) in STZ-treated animals and acute inflammatory changes (accumulation of neutrophilic granulocytes, vascular dilation, follicular hyperplasia) in Con A-treated animals. X-Gal staining confirmed the presence of tumour cells in the LNs of the injected side of tumour-inoculated mice. In the chronic lymphadenitis model, FDG uptake increased 3.0+/-0.1 fold [from 2.7+/-0.2 to 8.2+/-1.2 percent of injected dose per gram tissue (%ID/g)] and MET uptake 2.0+/-0.01 fold (from 4.5+/-0.6 to 9.2+/-1.1 %ID/g). In the acute lymphadenitis model, FDG uptake increased 3.9+/-0.3 fold (from 2.7+/-0.2 to 10.6+/-2.4 %ID/g) and MET uptake 1.9+/-0.1 fold (from 4.5+/-0.6 to 8.5+/-1.4 %ID/g). In contrast, FET uptake in both lymphadenitis models (1.0+/-0.03 and 1.2+/-0.04 fold) was not significantly different from that in controls (from 4.2+/-0.3 to 4.7+/-0.7 and to 5.1+/-0.4 %ID/g, respectively). Uptake of all three tracers in tumour-infiltrated LNs was significantly higher than that in control LNs. FDG uptake increased 2.8+/-0.15 fold (from 2.7+/-0.2 to 7.6+/-1.3%ID/g), MET uptake 1.7+/-0.11 fold (from 4.5+/-0.6 to 7.5+/-1.3 %ID/g) and FET uptake 2.4+/-0.15 fold (from 4.2+/-0.3 to 10.0+/-1.8 %ID/g). MET and FDG uptake was similar or higher in inflammatory than in tumour-infiltrated LNs ( P=0.01 and P<0.01, respectively). In contrast, uptake of FET showed no overlap between tumour-infiltrated and inflammatory LNs ( P<0.00001). In conclusion, tumour-infiltrated and inflammatory LNs could not be differentiated by means of FDG and MET uptake. FET, in contrast, proved to be a specific tracer for differentiating between tumour-infiltrated and inflammatory LNs in the murine models studied.

Needle aspiration as a diagnostic tool and therapeutic modality in suppurative lymphadenitis following Bacillus Calmette Guerin vaccination

OBJECTIVES

Outbreaks are known to occur after Bacillus Calmette Guerin (BCG) vaccination. An outbreak of suppurative lymphadenitis in 18 infants, following BCG vaccination is reported from Sikkim, with incidence of 8.6%. The outbreak occurred after a change of vaccine.

METHODS

In a prospective study the cases of suppurative lymphadenitis were diagnosed by needle aspiration cytology and culture of the material aspirated and managed only with repeated needle aspiration and no antitubercular treatment was given.

RESULTS

Cytomorphology revealed necrosis alone in 66.6% and necrotizing granulomas in 22.2%. Acid and alcohol fast bacilli were detected in 77.7% cases. Mycobacterium bovis was isolated in eight cases. One case of staphylococcal suppurative lymphadenitis was detected. Sixteen cases were managed with weekly aspiration with mean period of resolution in eight weeks.

CONCLUSIONS

Needle aspiration is useful in the diagnosis and effective in the management of these cases. No antitubercular treatment is desired and required in the cases of suppurative lymphadenitis following BCG vaccination.

[Adverse events following immunization with BCG vaccine in Poland 1994-2000]

BACKGROUND

In Poland, since 1955 BCG mass vaccinations have been compulsory. During the last two decades the vaccination program has been developed and includes: 1) primary vaccination of the newborn, 2) vaccination of children aged 7 and 12, and 3) revaccination of 18 year old adolescents. More than 95% of newborns and about 80% of older children of this population have been vaccinated. BCG vaccine being in use in Poland bases on the Brazilian/Moreau sub strain and has been producing by the Polish Laboratory. Since 1994 the central register of adverse events of BCG has been introduced by National Tuberculosis and Lung Diseases Institute (NTLDRI).

OBJECTIVES

The aim of this study was to evaluate the frequency, trends and clinical type of adverse events after BCG vaccination. In addition, correctness of case-finding and treatment of BCG complications was evaluated.

METHODS

From January 1, 1994 to December 31, 2000 individual data on adverse events, on special card was reported to NTLDRI. Categories of BCG complications was based on classifications proposed by A. Lotte.

RESULTS

Data of 7,354,780 BCG vaccinated persons was analyzed. Of them 1,559 cases reported AEFI. From the further analysis 98 cases with insufficient data were excluded. The frequency of these cases has been estimated to be 0.2@1000 (2 per 100,000 vaccinated) and was stabile. Among AEFI cases, 773 reported local complication (ulcer, abscess, K.F.) and 647 (44.3%) lymphadenitis including 353 cases with enlargement of lymph nodes and 287 cases of suppurative lymphadenitis (4 per 100,000 vaccinated). Majority of AEFI cases were infants (76%). Only 1 case (infant) with disseminated BCG disease, probably due to the partial interferon gamma receptor deficiency, was reported. Main errors in the diagnosis of complications and the management of adverse events after BCG vaccination were lack of data on the diameter of local changes and size of lymph nodes, as well as attempts to remove the lymph nodes.

CONCLUSION

The results of the study indicate that BCG vaccinations in Poland rarely produce adverse reactions and therefore may be considered as safe method of tuberculosis prevention. Adverse reactions to BCG appears to be underreported. Surveillance of adverse reactions to vaccines should be included in the national immunization program.

Inhalation toxicity studies of aqueous dispersion resin

Aqueous dispersion resin (ADR) is a water-based acrylate copolymer designed to allow a range of ethanol concentrations for hair-spray formulations. A series of inhalation (whole-body) aerosol toxicity studies, including acute, 9-day, and 90-day exposures, was conducted to determine any toxicological effects for ADR. An acute study of ADR was conducted for 4 h with a 14-day observation period. The maximum ADR aerosol concentration was 1.07 (+/- 0.04) mg/L with a mass medium aerodynamic diameter (MMAD) value of 1.46 microm and a geometric mean (sigma(g)) of 1.42. No deaths or exposure-related lesions were observed. Thus, the LC50 value was greater than 1.07 mg/L. For the 9-day study, each group contained 10 animals/sex and was exposed for 2 h/day. The mean exposure concentrations (+/- standard deviation) were 244 (+/- 39.6), 543 (+/- 71.9), and 843 (+/- 186.2) mg/m(3) for the 250-, 500-, and 1000-mg/m(3) groups, respectively. The mean MMADs were 2.83, 2.90, and 4.09 microm for the 250-, 500-, and 1000-mg/m(3) groups, respectively, with sigma(g) values ranging from 3.15 to 6.22. Unkempt fur and alopecia in the males and females from the 1000-mg/m(3) group at sacrifice were the only exposure-related clinical signs observed. Increased lung weights in the 500- and 1000-mg/m(3) exposure groups were found. Histopathological effects, such as alveolar histiocytosis and interstitial pneumonitis, were also noted in these two exposure groups. For the 90-day study, 10 animals per sex were included in each group with a 6-wk recovery group of 5 female rats/group. Exposures were conducted for 2 h/day. The mean exposure concentrations were 30.4 (+/- 2.3), 102 (+/- 11.6), and 308 (+/- 19. 3) mg/m(3) with mean MMADs of 3.09, 2.64, and 2.67 microm and sigma(g) values ranging from 3.54 to 3.90 for exposure concentrations of 30, 100, and 300 mg/m(3), respectively. The only findings at the 90-day sacrifice were increased lung weights for the males and females in the 300-mg/m(3) group and males in the 100-mg/m(3) group. For the 6-wk recovery sacrifice of the females, the lung weights for the 300- and 100-mg/m(3) groups were increased. Histopathological effects at the 90-day sacrifice included alveolar histiocytosis and lymphadenitis in the mediastinal lymph nodes in the 100- and 300-mg/m(3) exposure groups for males and females, while alveolar histiocytosis, intraalveolar cellular debris, lymphadenitis in the mediastinal lymph nodes, and/or interstitial pneumonitis were noted in these 2 exposure groups of the females after the 6-wk recovery period. Animals exposed for 90 days to 100 and 300 mg/m(3) for 2 h had increased lung weights. However, no effects were observed in the 30-mg/m(3) exposure group. Thus, under the conditions of the present 90-day study, a no-observable-effect level (NOEL) was found to be 30 mg/m(3).

[BCG vaccination: characteristics of drugs and causes of vaccinal complications]

Series of BCG and BCG-M vaccines causing complications in children vaccinated in Russia's areas in 1995 were checked up. All the series met the Russian and international specifications for BCG and BCG-M vaccines. The incidence of postvaccinal lymphadenitis was 5 times less than the limit laid down by an official article. The properties of the agents produced no significant effect on the number and type of postvaccinal complications. The risk for complications was much less when BCG-M was used. The risk factors were defects of intradermal vaccine administration and contaminant abnormalities prior to vaccination and at the moment of local vaccinal response.

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 individuals. Severe and/or late complications have been associated with impairment of cell-mediated immunity. A case of BCG lymphadenitis in a vertically 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, his HIV infection was diagnosed after his mother had died from AIDS. At that time his CD4 count was 739 cells/microL. In the course of the following years, his CD4 count declined steadily, until it reached a low of about 20 cells/microL at the age of 5.5 years. He was troubled with recurring respiratory infections and one incidence of severe pancreatitis. 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 tests showed an infection with Mycobacterium bovis BCG variety. The CD4 count at that time was 16 cells/microL, polymerase chain reaction showed 220,000 RNA copies/mL. There were no signs of dissemination. Antitubercular agents were administered, and an antiretroviral combination therapy was started. The patient was discharged from the hospital after approximately 2 months. After an uneventful period of 9 months, the boy, still on antitubercular medicine, exhibited a secreting fistula in his left axilla, again due to Mycobacterium bovis, BCG variety. The fistulous tissue was removed surgically, and the antitubercular treatment was given intravenously for almost 3 months before being changed to an oral application. In addition, the antiretroviral regimen was completely exchanged. The case presented illustrates that there is a risk of very late complications in HIV-infected individuals, even when they are vaccinated when they are asymptomatic newborns. Although the risk seems 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 countries with high medical standards, where HIV-infected children are surviving for longer periods of time.

Diesel exhaust particles and carbon black have adjuvant activity on the local lymph node response and systemic IgE production to ovalbumin

The possible adjuvant effect of diesel exhaust particles (DEP) on the response to the model allergen ovalbumin (OA) was studied in BALB/c mice using the popliteal lymph node (PLN) assay. In addition to changes in PLN weight, cell numbers and cell proliferation, specific serum IgE anti-OA antibody levels were measured. OA inoculated together with DEP into one hind footpad gave a significantly augmented response (increase in weight, cell numbers and cell proliferation) in the draining popliteal lymph node as compared to DEP or OA alone. Also, the local lymph node response was of longer duration when DEP were given with the allergen. Experiments in thymus-deficient nu/nu mice indicated that the lymph node response observed in BALB/c mice was of a specific immunologic character and not an unspecific inflammatory reaction. The OA-specific IgE response was increased in mice receiving OA together with DEP as compared to the response in mice receiving OA without DEP. Carbon black (CB) was given with and without OA in some experiments, as a surrogate for the non-extractable core of DEP. CB was found to resemble DEP in its capacity to increase the local lymph node response and serum specific IgE response to OA, but CB appeared to be slightly less potent than DEP. Thus, both DEP and CB had a significant adjuvant effect on the local immune-mediated inflammatory response and on the systemic specific IgE response to allergen. The results indicate that the non-extractable particle core contributes substantially to the adjuvant activity of DEP.

Cytomorphologic patterns in Calmette Guerin bacillus lymphadenitis

OBJECTIVE

To study the cytomorphologic patterns of Calmette Guerin bacillus (BCG) lymphadenitis and compare it to those of tuberculous lymphadenitis.

STUDY DESIGN

A retrospective cytomorphologic study of 136 cases of clinically diagnosed BCG adenitis. All fine needle aspiration smears of lymphadenitis in the age group 2 months to 2 years during a three-and-half-year period were analyzed.

RESULTS

Three distinct cytomorphologic patterns were seen in 112 cases. They were acid-fast bacilli in a necrotic background (62), granulomas with necrosis (47) and granulomas in a reactive lymphoid background (3).

CONCLUSION

The cytomorphologic patterns in BCG lymphadenitis were similar to those seen in tuberculous lymphadenitis; however, an exudative response and high acid-fast bacillus positivity was seen more frequently in BCG lymphadenitis. Moreover, Ziehl-Neelsen staining helped to distinguish these cases from pyogenic abscesses.

Is BCG vaccine innocent?

Four patients admitted to the Hacettepe University Department of Pediatric Surgery between 1987 and 1995, two with Bacille Calmette-Guérin (BCG) lymphadenitis and two with multisystem postvaccination tuberculosis (MPT), are presented. The hospital records and records of the Ministery of Health Tuberculosis Control Department were evaluated to determine the complications of BCG vaccine. The most common complication was lymphadenitis with or without suppuration (0.3 per thousand - 3 per thousand). Surgical intervention was required in two BCG lymphadenitis cases and two cases of MPT. Involved lymph nodes were excised in two lymphadenitis cases. Colostomy and percutaneous nephrostomy was performed in the first case of MPT in addition to triple antituberculous drug therapy. Although BCG lymphadenitis is self limited, chronically discharging nodes and tumor-like lymphadenopathy masses need to be excised. On the other hand, MPT has a silent nature with resistance to antituberculous drug therapy. Surgical intervention may be required, directed to the involved systems.

Expression of interleukin-1 beta, interleukin-6 and tumour necrosis factor alpha by macrophages in canine lymph nodes with mineral-associated lymphadenopathy, granulomatous lymphadenitis or reactive hyperplasia

The distribution of CD3+ T lymphocytes and the expression of interleukin-1 beta (IL-1 beta), interleukin-6 (IL-6) and tumour necrosis factor alpha (TNF alpha) by macrophages in canine lymph nodes with mineral-associated lymph-adenopathy, granulomatous lymphadenitis or reactive hyperplasia was examined immunohistochemically. In areas of preserved lymph node architecture, CD3+ T lymphocytes were located in the paracortex, with scattered cells in the follicular mantle and germinal centre, and small aggregates in the medullary cords. T cells were prominent within areas of diffuse granulomatous inflammation and formed a peripheral rim around microgranulomas. TNF alpha expression was demonstrated in macrophages from seven of 11 dogs with mineral-associated lymphadenopathy, one of five dogs with granulomatous lymphadenitis and three of five with reactive hyperplasia. Positive macrophage staining for IL-1 beta and IL-6 was seen in two lymph nodes with reactive hyperplasia. Lymph nodes from control (clinically normal) dogs showed no evidence of cytokine expression. Neutrophils expressing IL-1 beta were observed within the medullary sinuses of two lymph nodes with mineral-associated lymphadenopathy and one with reactive hyperplasia, and in the inflammatory infiltrate in one lymph node with granulomatous lymph-adenitis. The sensitivity of immunohistochemical examination as a means of detecting cytokines in abnormal tissue is discussed.

[Axillary silicon lymphadenopathy after breast augmentation]

We report on a case of axillary lymphadenopathy in a 40-year-old woman secondary to a bilateral silicone augmentation mammoplasty which occurred 10 years after surgery. Microscopic silicone leakage ("bleeding") from an intact prothesis lead to sizeable lymph node enlargement. The suspected malignant tumour (metastasis/malignant lymphoma) could be ruled out by histological examination of the lymph node.

[Four cases of similar Hexheimer's reaction during the initial chemotherapy for tuberculosis bacillus]

In the report, 4 patients with similar Hexheimer's reaction during initial chemotherapy for pulmonary tuberculosis were presented. The literatures on clinical manifestations, predisposing factors, pathogenic mechanism, pathological changes, diagnosis and management of Hexheimer's reaction are reviewed.

BCG vaccination in India and tuberculosis in children: newer facets

With the extended programme of immunisation and since 1985 the universal programme of immunisation and the coverage status of BCG vaccination in India has been very good, although it is still unsatisfactory in the eastern states. It is emphasized that BCG vaccination cannot prevent natural tuberculous infection of the lungs and its local complications, although it reduces the haematogenous complications of primary infection. However, this is not true for malnourished children who, inspite of BCG vaccination, develop serious, and often fatal types of tuberculosis such as miliary, meningitic and disseminated tuberculosis. The tuberculin anergy in malnourished children, is mainly responsible for high morbidity and mortality. BCG vaccinated, well-nourished children manifest modified patterns of tuberculous disease, following infection. The most important manifestation is the increased incidence of intrathoracic tuberculosis, specially enlargement of the various groups of mediastinal nodes and their local complications. Localisation of the disease by T cell immunity, due to BCG vaccination is responsible for this and the much lower incidence of haemotological complications such as neurotuberculosis and disseminated disease. In these children, the clinical picture of neurotuberculosis is also modified, with a tendency for more localised involvement of the brain and meninges. Similarly, vaccinated children may present with hepatomegaly, splenomegaly or isolated organ disease. It is important to relearn the new patterns of tuberculosis disease seen in vaccinated, non-malnourished children, and to a lesser extent in children with grade 1 to 2 protein energy malnutrition (PEM). With these limitations of BCG vaccination, other strategies like chemoprophylaxis need multicentric trials in high risk children, in different parts of the country.

Complications of BCG vaccinations in rural Haiti

This study investigated an outbreak of axillary lymphadenitis and abscesses after Bacillus Calmette-Guérin vaccination among rural Haitian children treated at the Hospital Albert Schweitzer from January 1986 through March 1991. Seventy-seven cases of vaccine-related complications were identified, all among children immunized before the age of 1 year. The proportions of children with complications were 0.017% for 1986 through 1989, 0.91% for 1990, and 2.2% for January through March 1991.

Ocular changes induced in the beagle dog by intravenous infusion of a novel dopaminergic compound, FPL 65447

FPL 65447, a selective D1 receptor agonist with a potential for the acute treatment of renal and cardiac failure and of sepsis and septic shock, was administered to beagle dogs by continuous intravenous infusion for a maximum of 14 days. Ophthalmoscopical examination revealed dose-related changes in the eye and associated structures, consisting of foci of retinal discolouration, corneal changes including oedema, keratitis, opacities and neovascularisation, and inflammation of the iris, periorbital tissues, and adnexa. Microscopical examination confirmed the presence of inflammatory lesions in the eye. These were predominantly histiocytic and were mainly focal circumscribed lesions. More diffuse inflammation with a granulocytic and lymphocytic component was also encountered in the limbus and uveal tract. A predominantly interstitial histiocytic adenitis involving various glandular structures associated with the eye and adnexa was also identified. Possible mechanisms to account for the histiocytic changes are discussed.

Inguinal lymphadenopathy due to metal release from a prosthesis. A case report

We report the case of a 19-year-old man with inguinal lymphadenopathy caused by metallic debris from the loosening of a prosthesis inserted after tumour resection. Large amounts of wear debris may be released from such massive replacements, and surgeons should be aware of the range of possible adverse effects.

Activation of CD4+ and CD8+ lymphocyte subsets by streptozotocin in murine popliteal lymph node (PLN) test

Time-related and dose-related popliteal lymph node (PLN) enlargement and lymphocyte subset alterations owing to subcutaneous (s.c.) injection of streptozotocin (STZ) into the foot pad were determined in (C57BL/6 x DBA/2)F1 [B6D2F1] mice. Early cell activation and time-related changes in T and B lymphocyte subsets were monitored during the onset of STZ-induced lymphoproliferative reaction by flow cytometry and immunophenotyping of lymphocyte subsets stained with a panel of monoclonal antibodies. Examination of cell size and chromatin decondensing for T and B cell subsets revealed differences in their activation profiles during the early phase of STZ-induced lymph node enlargement. The kinetics of the reaction showed initial activation and proliferation of CD4+ cells associated with accumulation of CD8+ and B cells. Subsequently CD8+ cells were activated and proliferated, but there was no evidence of early or late B cell activation as shown by the lack of increase in cell size or nuclear decondensation and the low and transient synthesis of immunoglobulins. The activation characteristics for CD4+ and CD8+ cell subsets in STZ-induced node enlargement were found to be analogous with T cell activation in acute allogeneic graft-versus-host (GVH) reaction in which the F1 recipient differed from the parent at both class I and II MHC loci. Our data support a central role for T cell activation in the induction of STZ-related PLN enlargement and suggest that recirculatory host B cells can play a major role in early node enlargement.

Occurrence of suppurative lymphadenitis after a change of BCG vaccine

BCG vaccines are the oldest vaccines in use today, but the protective effect of the vaccination is still controversial. The risk of contracting tuberculosis is low compared with the possible complications after this vaccination. In Austria the formerly used BCG vaccine was not available in the required amount and another vaccine was released by the drug authorities. This product, with a more virulent strain, was used between August and December 1990, and this increased the incidence of complications. Eighty four of 1950 vaccinated newborn babies developed severe suppurative lymphadenitis three to 28 weeks after the vaccination, and surgical treatment was found to be necessary. Isoniazid treatment did not prove to be successful when the lymph node exceeded a certain size. Culture was successful in 46% up to week 20; after 20 weeks no culture became positive. All cultured bacteria were isoniazid sensitive. The question of general vaccination is raised and several points were considered before we came to the conclusion that except for high risk groups a general vaccination programme for neonates is not justified in Western countries.