Letter to the Editor
BCGitis in children
BCGite nas crianças
a Pulmonology Department, Centro Hospitalar de Vila Nova de Gaia/Espinho (CHVNG), Vila Nova de Gaia, Portugal
b Center of Pulmonology Diagnostics (CDP), Vila Nova de Gaia, Portugal
c Public Health Department, ARS Norte, I.P. Porto, Portugal
d Department of Epidemiology, Preventive Medicine and Health of Medicine Faculty, Oporto University, Porto, Portugal
e Institute of Public Health, Porto University, Porto, Portugal
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"apellidos" => "Ladeira" "email" => array:2 [ 0 => "ines.ladeira@chvng.min-saude.com" 1 => "ines.ladeira@chvng.min-saude.pt" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "I." "apellidos" => "Carvalho" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Correia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 3 => array:3 [ "nombre" => "A." 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Porto, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Epidemiology, Preventive Medicine and Health of Medicine Faculty, Oporto University, Porto, Portugal" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Institute of Public Health, Porto University, Porto, Portugal" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "BCGite nas crianças" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 561 "Ancho" => 750 "Tamanyo" => 41669 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Left axillary lymphadenitis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The bacille Calmette‐Guérin (BCG) vaccine is a live‐virus vaccine with attenuated strains of Micobacterium bovis,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> currently reaching >80% of infants in countries such as Portugal<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> (97% coverage in 2011<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>) where it is part of the childhood immunization programme.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Adverse effects are rare and mostly include local reactions – lymphadenitis is the most common event,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3,4</span></a> 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.</p><p id="par0010" class="elsevierStylePara elsevierViewall">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) – <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. 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).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Our rate of lymphadenitis is lower than those presented in previous studies<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> – early vaccination is associated with a lower risk<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and the lower the dose administered, the lower the risk of adverse events<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> – we had 0.05<span class="elsevierStyleHsp" style=""></span>mL administered at birth.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The nurses’ experience does not seem to affect the outcome<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> but it could not be evaluated in our context.</p><p id="par0020" class="elsevierStylePara elsevierViewall">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%.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The risk of suppuration is higher in younger ages and in those who rapidly develop BCGitis<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> – our suppurative cases developed lymphadenitis less than 4 months after being vaccinated.</p><p id="par0025" class="elsevierStylePara elsevierViewall">There is no consensus about the management of BCGitis but treatment is not usually necessary for local reactions<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and no clear benefit of active treatment (pharmacologic treatment, needle aspiration or surgical excision) over expectant attitude<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> was found, although some studies advise aspiration or surgery to reduce healing time and adverse cosmetic effects.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> Although two of our children had spontaneous drainage without medical or surgical treatment, none had sequelae.</p><p id="par0030" class="elsevierStylePara elsevierViewall">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.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 561 "Ancho" => 750 "Tamanyo" => 41669 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Left axillary lymphadenitis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "World Health Organization: position paper. 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| 2023 January | 280 | 32 | 312 |
| 2022 December | 295 | 32 | 327 |
| 2022 November | 428 | 46 | 474 |
| 2022 October | 279 | 44 | 323 |
| 2022 September | 295 | 32 | 327 |
| 2022 August | 290 | 38 | 328 |
| 2022 July | 278 | 54 | 332 |
| 2022 June | 321 | 42 | 363 |
| 2022 May | 320 | 61 | 381 |
| 2022 April | 280 | 57 | 337 |
| 2022 March | 297 | 57 | 354 |
| 2022 February | 190 | 47 | 237 |
| 2022 January | 224 | 53 | 277 |
| 2021 December | 165 | 57 | 222 |
| 2021 November | 195 | 47 | 242 |
| 2021 October | 209 | 46 | 255 |
| 2021 September | 236 | 70 | 306 |
| 2021 August | 244 | 38 | 282 |
| 2021 July | 318 | 32 | 350 |
| 2021 June | 369 | 61 | 430 |
| 2021 May | 314 | 49 | 363 |
| 2021 April | 757 | 131 | 888 |
| 2021 March | 603 | 55 | 658 |
| 2021 February | 436 | 41 | 477 |
| 2021 January | 393 | 59 | 452 |
| 2020 December | 424 | 54 | 478 |
| 2020 November | 363 | 38 | 401 |
| 2020 October | 280 | 41 | 321 |
| 2020 September | 413 | 42 | 455 |
| 2020 August | 382 | 60 | 442 |
| 2020 July | 447 | 56 | 503 |
| 2020 June | 445 | 38 | 483 |
| 2020 May | 415 | 45 | 460 |
| 2020 April | 405 | 21 | 426 |
| 2020 March | 362 | 38 | 400 |
| 2020 February | 427 | 51 | 478 |
| 2020 January | 523 | 44 | 567 |
| 2019 December | 433 | 33 | 466 |
| 2019 November | 431 | 41 | 472 |
| 2019 October | 563 | 46 | 609 |
| 2019 September | 499 | 31 | 530 |
| 2019 August | 546 | 51 | 597 |
| 2019 July | 629 | 37 | 666 |
| 2019 June | 562 | 30 | 592 |
| 2019 May | 628 | 35 | 663 |
| 2019 April | 574 | 51 | 625 |
| 2019 March | 543 | 50 | 593 |
| 2019 February | 430 | 25 | 455 |
| 2019 January | 529 | 45 | 574 |
| 2018 December | 341 | 22 | 363 |
| 2018 November | 73 | 4 | 77 |
| 2018 October | 159 | 12 | 171 |
| 2018 September | 189 | 7 | 196 |
| 2018 August | 408 | 24 | 432 |
| 2018 July | 378 | 17 | 395 |
| 2018 June | 266 | 17 | 283 |
| 2018 May | 380 | 16 | 396 |
| 2018 April | 320 | 27 | 347 |
| 2018 March | 296 | 27 | 323 |
| 2018 February | 199 | 8 | 207 |
| 2018 January | 158 | 19 | 177 |
| 2017 December | 173 | 20 | 193 |
| 2017 November | 200 | 12 | 212 |
| 2017 October | 206 | 21 | 227 |
| 2017 September | 173 | 21 | 194 |
| 2017 August | 174 | 19 | 193 |
| 2017 July | 115 | 16 | 131 |
| 2017 June | 193 | 21 | 214 |
| 2017 May | 239 | 18 | 257 |
| 2017 April | 156 | 12 | 168 |
| 2017 March | 190 | 21 | 211 |
| 2017 February | 288 | 6 | 294 |
| 2017 January | 132 | 9 | 141 |
| 2016 December | 153 | 11 | 164 |
| 2016 November | 190 | 9 | 199 |
| 2016 October | 213 | 9 | 222 |
| 2016 September | 247 | 13 | 260 |
| 2016 August | 122 | 20 | 142 |
| 2016 July | 81 | 15 | 96 |
| 2016 May | 2 | 10 | 12 |
| 2016 April | 128 | 1 | 129 |
| 2016 March | 158 | 17 | 175 |
| 2016 February | 204 | 23 | 227 |
| 2016 January | 177 | 18 | 195 |
| 2015 December | 190 | 23 | 213 |
| 2015 November | 159 | 22 | 181 |
| 2015 October | 157 | 17 | 174 |
| 2015 September | 171 | 17 | 188 |
| 2015 August | 152 | 14 | 166 |
| 2015 July | 141 | 13 | 154 |
| 2015 June | 92 | 7 | 99 |
| 2015 May | 111 | 13 | 124 |
| 2015 April | 108 | 22 | 130 |
| 2015 March | 106 | 6 | 112 |
| 2015 February | 109 | 9 | 118 |
| 2015 January | 96 | 22 | 118 |
| 2014 December | 106 | 17 | 123 |
| 2014 November | 123 | 24 | 147 |
| 2014 October | 147 | 13 | 160 |
| 2014 September | 121 | 19 | 140 |
| 2014 August | 103 | 33 | 136 |
| 2014 July | 92 | 21 | 113 |
| 2014 June | 114 | 31 | 145 |
| 2014 May | 125 | 57 | 182 |
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