Surgical management of BCG vaccine-induced regional axillary lymphadenitis in HIV-infected children.

Abstract

There are as yet no clear surgical guidelines for the management of BCG vaccine-induced regional axillary lymphadenopathy. The aim of this study was to evaluate the management of the condition and to suggest possible management strategies. A retrospective study was undertaken of 23 cases of suspected ipsilateral BCG adenitis following neonatal BCG inoculation (2001 - 2004). Diagnosis of a BCG infection was confirmed by culture and/or gastric washout. The age of the patient and mode of presentation, imaging findings, and results of tuberculin skin testing (Mantoux test) were documented. Because of a change in management policy the first group of patients treated by primary surgery were compared with those treated by fine-needle aspiration (FNA). The influence of HIV status on outcome was assessed. Surgical complications and outcome were analysed. Twenty-three children under 13 years of age (mean age 8.8 months, male/female ratio 1.9:1) were evaluated. Eighteen patients tested positive for HIV and 5 were HIV-negative. A positive culture for BCG bacillus was identified in 19 cases (83%) - by FNA (N=13, 68%), on pus swab (N=3, 16%), at surgery (N=1, 5%), and by gastric washing (N=2, 11%). Three HIV-negative children had granulomas on histological examination without a positive culture. Forty-five per cent of the 11 patients treated early in the study period by primary surgery (drainage/biopsy) had complications, which included a difficult anaesthetic induction and technical surgical difficulties. The postoperative incidence of wound dehiscence/infection was extremely high in this group and 18.2% developed postoperative cutaneous sinuses. Following a change in management policy, the following 12 patients, with a comparable HIV incidence, treated by initial conservative management, had a much lower incidence of post-procedural complications. This study confirms a high perioperative complication rate associated with the primary surgical treatment of BCG lymphadenitis in both HIV-positive and negative patients. Primary surgical treatment (incisional drainage or biopsy) is therefore not considered an ideal form of management in BCG lymphadenitis because of the high fistulisation and poor wound healing, especially in the HIV-positive patient. It should be avoided as the initial approach, with needle aspiration being preferred. Surgery should therefore be confined to the unusual event of real doubt about the underlying diagnosis and the treatment of suppurative complications.