The bacille Calmette-Guérin (BCG) vaccine is a live-bacteria vaccine with attenuated strains of Micobacterium bovis,1,2 currently reaching >80% of infants in countries such as Portugal2 (97% coverage in 20112) where it is part of the childhood immunization programme.1 Adverse effects are rare and mostly include local reactions – lymphadenitis is the most common event,1,3,4 characterized by ipsilateral regional lymph nodes enlargement (nonsuppurative or suppurative), 2–8 months after vaccination. There is no consensus about the best treatment for lymphadenitis.
From 2010 to 2012, 4209 children were born in Vila Nova Gaia, of which 4059 received BCG vaccine and 4 cases of BCGitis occurred in our center – 3 were boys and none had immunity disorders or known family diseases. In all of them, nodal involvement was ipsilateral to BCG administration, without associated symptoms or physical examination abnormalities and happened less than 1 year after vaccination (1–10 months). One child had persistent non-suppurative lymphadenitis and three developed suppurative disease (1–3 months after node enlargement) – Fig. 1. Two children had lymph-nodes surgical exeresis – one with persistent axillary lymph-node (aspirative biopsy positive for Micobacterium bovis) and other with suppurative lymphadenitis (exeresis during suppuration phase). Two others (suppurative lymph-nodes) had spontaneous drainage (positive for Micobacterium bovis) with complete fistulae resolution for 2–9 months (without being submitted to surgery, needle aspiration or antibiotics).
Our rate of lymphadenitis is lower than those presented in previous studies3 – early vaccination is associated with a lower risk3 and the lower the dose administered, the lower the risk of adverse events3 – we had 0.05mL administered at birth.2 The nurses’ experience does not seem to affect the outcome3 but it could not be evaluated in our context.
The nonsuppurative form usually has a benign clinical course. The suppurative form is characterized by a suppurative material collection that can rupture with persistent caseous discharge and wound healing taking several months – secondary bacterial infection, scarring or keloid formation are common. Our incidence of suppurative lymphadenitis is similar to worldwide data – 30–80%.1 The risk of suppuration is higher in younger ages and in those who rapidly develop BCGitis5 – our suppurative cases developed lymphadenitis less than 4 months after being vaccinated.
There is no consensus about the management of BCGitis but treatment is not usually necessary for local reactions4 and no clear benefit of active treatment (pharmacologic treatment, needle aspiration or surgical excision) over expectant attitude4 was found, although some studies advise aspiration or surgery to reduce healing time and adverse cosmetic effects.4,5 Although two of our children had spontaneous drainage without medical or surgical treatment, none had sequelae.
Management of these cases should consider the risk of invasive procedures versus the length of time for resolution and the cosmetic effects of conservative measures.
