Bacille Calmette-Guérin Infection Research Articles

BCG infection dose guides dendritic cell migration and T cell priming in the draining lymph node.

In contrast to delayed-type hypersensitivity (DTH) and other hallmark reactions of cell-mediated immunity that correlate with vaccine-mediated protection against Mycobacterium tuberculosis, the contribution of vaccine dose on responses that emerge early after infection in the skin with Bacille Calmette-Guérin (BCG) is not well understood. We used a mouse model of BCG skin infection to study the effect of BCG dose on the relocation of skin Dendritic cells (DCs) to draining lymph node (DLN). Mycobacterium antigen 85B-specific CD4+ P25 T cell-receptor transgenic (P25 TCRTg) cells were used to probe priming to BCG in DLN. DC migration and T cell priming were studied across BCG inocula that varied up to 100-fold (104 to 106 Colony-forming units-CFUs). In line with earlier results in guinea pigs, DTH reaction in our model correlated with BCG dose. Importantly, priming of P25 TCRTg cells in DLN also escalated in a dose-dependent manner, peaking at day 6 after infection. Similar dose-escalation effects were seen for DC migration from infected skin and the accompanying transport of BCG to the DLN. BCG-triggered upregulation of co-stimulatory molecules on migratory DCs was restricted to the first 24 hour after infection and was independent of BCG dose over a 10-fold range (105 to 106 CFUs). The dose seemed to be a determinant of the number of total skin DCs that move to the DLN. In summary, our results support the use of higher BCG doses to detect robust DC migration and T cell priming.

Clinical presentation of bacille Calmette-Guérin (BCG) infections after BCG instillation therapy.

To investigate the timing of the clinical presentation of various types of bacille Calmette-Guérin (BCG) infections in a Finnish population of patients with bladder cancer treated with BCG instillation therapy. We identified patients with a history of post-instillation BCG infection from 1996 to 2016 using the Finnish Cancer Registry and the Finnish National Infectious Diseases Registry. We categorised infections as systemic if the infection was found in the non-urogenital system and genitourinary (GU) if the infection affected the urogenital tract. We calculated the time interval between the last BCG instillation and the presentation of the infection. The infection was considered late if the time interval was ≥1 year. A total of 100 patients with BCG infection were identified during the study period. In all, 39 (39%) infections presented as systemic and 61 (61%) were in the GU tract. The majority of the systemic infections presented rapidly after the last instillation, while five (13%) presented after a latency of ≥1 year. The presentation of GU infections was more heterogeneous, with 12 (20%) presenting as late infections. This study confirms the concept of early and late infection types, especially among systemic infections. However, late infections appeared to be rarer than previously described. Urologists should be aware of the possibility of late BCG infection if patients develop symptoms even several years after the BCG regimen.

GENETIC AND CLINICAL PROFILING OF MENDELIAN SUSCEPTIBILITY TO MYCOBACTERIAL DISEASE PATIENTS; SINGLE CENTER EXPERIENCE

Objective: Mendelian susceptibility to mycobacterial disease (MSMD) is a subgroup of primary immunodeficiencies which develops with the Bacille Calmette–Guérin (BCG) vaccine or non-tuberculous mycobacterial infections. The clinical symptoms have a broad spectrum, from localized to disseminated infections. Materials and Methods: Herein, we performed whole-exome sequencing (WES) on 13 patients with MSMD phenotype. All variants were confirmed by Sanger sequencing. The mean age was 8.41 years (min 3 – max 14 years), and the mean age of symptom onset was 4.6 years in our cohort. Results: We found previously identified IFNGR1 (n=1), IFNGR2 (n=1), TYK2 (n=1), IL12RB1 (n=1), and CYBB (n=1) gene variants in nine patients. Our patients mostly suffered from lymphadenitis (61.5%), osteomyelitis (38%), and miliary tuberculosis (31%). All patients except one had had the BCG vaccination. Two patients developed BCGitis after vaccination. Three patients suffered from disseminated BCG infection (BCGosis). Conclusion: Our findings show the importance of molecular diagnosis in patients with severe infections as an approach for understanding the genetic basis of infectious diseases and deciding on treatment options. The deficiency of IFN-mediated immunity genes plays a crucial role in the pathogenesis of MSMD and must be considered in pediatric patients with BCGitis.

Bacille Calmette-Guérin vaccine induced lymphadenitis in infants and children masquerading with tubercular lymphadenitis at tertiary care hospital in North India

Background: Bacille calmette–guerin (BCG) vaccine containing live-attenuated Mycobacterium bovis was first used in humans to prevent tuberculosis in 1921. It is a safe vaccine. However, there can be minor adverse reactions such as pain, swelling, and redness at local injection site. The lesser known severe adverse reactions such as lymphadenitis, BCG osteitis, and disseminated BCG infection can be present after BCG vaccination. Aims and Objectives: The aim of the study was to report the cases of BCG lymphadenitis diagnosed by fine needle aspiration cytology (FNAC) after BCG vaccination in infants and children. Materials and Methods: All the infants and children (1 month–2 years) who presented with regional lymphadenopathy for FNAC after BCG vaccination were included in the study. Results: Total 21 patients with BCG lymphadenitis were recruited. In all the cases, the lymphadenitis involved ipsilateral left axillary lymph nodes. In three patient sites of involvement included the left supraclavicular lymph nodes and in other three patients left cervical lymph nodes along with left axillary lymph node. Sixteen patients had suppurative granulomatous lymphadenitis (SGLA) on FNAC and positive for Ziehl–Neelsen (ZN) staining for acid fast bacilli (AFB), while rest nine had non-suppurative granulomatous lymphadenitis (NSGLA) with negative for ZN staining for AFB. Conclusion: Early diagnosis of BCG lymphadenitis can help in proper management. Furthermore, it can prevent unnecessary anti tubercular treatment in children.

Incidence of and mortality from Bacille Calmette-Guérin (BCG) infections after BCG instillation therapy.

To investigate the incidence of and mortality associated with Bacille Calmette-Guérin (BCG) infections in a Finnish population of patients with bladder cancer treated with BCG instillations. We conducted a nationwide register study and identified patients with BCG infections in Finland during 1996 to 2016 using the Finnish Cancer Registry and the Finnish National Infectious Diseases Register. We estimated the number of patients treated with BCG instillations based on data on national consumed BCG doses used to treat patients with bladder cancer, and calculated the annual incidence proportion of BCG infections. We further performed a detailed medical chart review to describe the clinical features and outcomes of the treated BCG infections. In total, 87 patients with BCG infection after BCG treatment of bladder cancer were identified. The incidence proportion increased gradually, yielding a cumulative incidence proportion of 2.5% during the latter half of the study period. BCG infections led to significant mortality, with 10% overall mortality and 17.5% mortality from systemic infections, which is notably higher than previously reported. The incidence proportion of BCG infections among bladder cancer patients treated with BCG has increased in Finland up to 2.5% at a nationwide level, with a notably higher mortality rate than previously reported.

A CASE OF RUPTURED MYCOTIC ANEURYSM AFTER DISSEMINATED MYCOBACTERIUM BOVIS INFECTION

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Dissemination is a rare complication of intravesical bacille Calmette-Guerin (BCG) therapy for bladder malignancy. CASE PRESENTATION: An 86 year-old male with medical history of atrial fibrillation, cerebrovascular accident, and bladder carcinoma treated with intravesical BCG who initially presented with worsening lower back pain. A contrast CT showed left psoas abscess abutting posterior and left lateral wall of the infrarenal abdominal aorta without evidence of aneurysm formation or contrast extravasation. Culture from the left psoas abscess aspirate returned positive for mycobacterium tuberculosis complex with a monoresistance pattern for Pyrazinamide consistent with the diagnosis of Mycobacterium Bovis(M.Bovis). He was started on a multidrug antitubercular regimen with a plan for close-follow up with serial imaging. After 3 months, he developed worsening back pain and was brought to the emergency room with increasing somnolence. Vitals were remarkable for hypotension and tachycardia. On physical examination, the patient was disoriented and had mild abdominal tenderness. Rest of the exam was unremarkable. His blood work revealed hemoglobin 6.2mg/dl and creatinine 2.2mg/dl. Abdominal CT angiography showed large left retroperitoneal hematoma and contained rupture of the infrarenal aortic aneurysm. He was resuscitated with blood products and anticoagulation was held. He underwent emergent endovascular aneurysm repair. His postoperative period was complicated by the deterioration of renal functions resulting in anuric renal failure. He was transitioned to hospice as hemodialysis was not consistent with his goals of care. DISCUSSION: BCG contains a weak strain of M. Bovis which is used as a vaccination against mycobacterium tuberculosis infection in some parts of the world and also as intravesical immunotherapy for the treatment of bladder cancer. Common side effects of intravesical BCG treatment include transient fever, fatigue, dysuria, or hematuria. Rarely, it can lead to disseminated infection leading to pneumonitis, prostatitis, hepatitis, or endovascular involvement. The pathogenesis of endovascular invasion by BCG is unclear but it is postulated to be associated with instrumentation of the bladder. Presentation of endovascular involvement may be subtle and is usually discovered after the development of complications like a ruptured aneurysm. Mycotic aneurysm related to disseminated BCG infection should be suspected based on relevant history. Diagnosis requires imaging as well as a specimen collection for microscopic analysis and culture. Mycobacterium Bovis isolates are inherently resistant to pyrazinamide. On biopsy, there is usually evidence of granulomatous inflammation. Management involves multidrug antitubercular regimen and surgical repair of the aneurysm. CONCLUSIONS: Physicians should be aware of late complications of intravesicular BCG administration. Reference #1: A. Steg, S. Adjiman, B. Debre BCG therapy in superficial bladder tumors—complications and precautions Eur Urol, 21 (suppl 2) (1992), pp. 35-40 Reference #2: J.M. LaBerge, R.K. Kerlan Jr, L.M. Reilly, T.A. Chuter Diagnosis please: Case 9: mycotic pseudoaneurysm of the abdominal aorta in association with mycobacterial psoas abscess—a complication of BCG therapy Radiology, 211 (1999), pp. 81-85 Reference #3: D.L. Lamm, P.M. van der Meijden, A. Morales, S.A. Brosman, W.J. Catalona, H.W. Herr, et al. Incidence and treatment of complications of bacillus Calmette-Guerin intravesical therapy in superficial bladder cancer J Urol, 147 (1992), pp. 596-600 DISCLOSURES: No relevant relationships by Shahrukh Arif, source=Web Response No relevant relationships by Firas Jafri, source=Web Response

Successful SCID gene therapy in infant with disseminated BCG

We present a case of an infant with X-linked severe combined immunodeficiency (XSCID) and disseminated Bacille Calmette-Guérin (BCG) infection, who enrolled on our XSCID gene therapy trial, in which newly diagnosed patients receive lentiviral-transduced, gene-corrected CD34+ hematopoietic stem cells after low-dose, targeted busulfan conditioning (NCT01512888).1 The patient was reported in our initial publication (patient #6), and we herein describe in detail his clinical course that was complicated by disseminated BCG infection.

Bacille Calmette-Guerin (BCG) complications in children with severe combined immunodeficiency (SCID)

Background: Bacille Calmette-Guerin (BCG) is included in the routine vaccination program in Gaza and the West Bank. Although safe, complications can occur and include local, extra-regional and disseminated BCG infection. Therefore it is contraindicated in immunodeficiencies. However, most infants are immunized prior to diagnosis of immunodeficiency. We report clinical and immunological characteristics of patients referred with severe combined immunodeficiency (SCID) who suffered from BCG complications.Methods: Files of patients referred for evaluation of immunodeficiency from January 2008 to February 2016 were retrieved. All patients have received BCG. Cell surface markers of peripheral blood mononuclear cells (PBMCs) were measured by immunofluorescent staining and flow cytometry. Serum concentrations of immunoglobulins were measured using nephelometry. Genetic diagnosis of SCID was made by direct Sanger sequencing of candidate genes. BCG complications were classified as: a) local; b) regional; c) distant; and d) disseminated disease.Results: Twenty-one children were diagnosed with SCID. BCG complications were diagnosed in 12 (57.1%). Eight patients developed local and regional disease (67%) and 4 (33%) had disseminated infection. Patients received at least three drugs: isoniazid, ethambutol and rifampicin. Outcome was relatively favorable with eight patients surviving (66.6%). No death related to BCG infection was observed. Disseminated disease was associated with reduced numbers of total lymphocytes, CD3 and CD8 levels (p < .05).Conclusions: Although high rates of BCG complications were observed, mortality was not increased and outcomes were good. Increased awareness in countries where BCG vaccine is not routinely administered and newborn screening programs for SCID could reduce complication rates.

The epidemiology of bacille Calmette-Guérin infections after bladder instillation from 2002 through 2017: a nationwide retrospective cohort study.

To describe incidence and clinical characteristics of bacille Calmette-Guérin (BCG) infections after BCG bladder instillation amongst patients with non-muscle-invasive bladder cancer in Denmark. We conducted a nationwide register-based cohort study in Denmark between 2002 through 2017. Patients with BCG infection were identified by cross-linking data from the Danish National Hospital Registry on patients treated with BCG instillations and patients diagnosed with tuberculosis according to the International Classification of Diseases 10, and data obtained from International Reference Laboratory of Mycobacteriology. Hospital records were reviewed for clinical information. During the study period, 6753 patients (5281 men; mean [SD] age 71.1(0.1)years) received BCG instillations, of which 66 patients (1%) developed BCG infections. There were no differences in age or Charlson Comorbidity Index between the patients in the study population stratified by BCG infection. The median (interquartile range) time from first BCG instillation until symptoms of BCG infection was 169.5(38-585)days. Extrapulmonary localisation of BCG infections (37 patients, 56.1%) was significantly more frequent than pulmonary BCG infections (20 patients, 30.3%; P<0.001). The most common extrapulmonary localisation was the genitourinary tract (29 patients, 78.4%). BCG infections after bladder instillation are rare, mainly affect male patients, and are most frequently extrapulmonary. BCG infections should be suspected despite a long time span between occurrence of symptoms and prior bladder instillation.

810. Diagnosis of BCG Aortitis by Plasma Metagenomic Sequencing

BackgroundThe use of intra-vesicular Bacille Calmette-Guerin (BCG) for bladder cancer can result in disseminated/endovascular BCG infection. The diagnosis of BCGosis in this setting is complicated by the risks of biopsy of an endovascular focus and the long duration of acid-fast bacilli (AFB) cultures.MethodsA 68-year-old male with a history of hypertension, aortic aneurysm (status post repair), and bladder cancer treated with intravesicular BCG complicated by BCGosis presented several years later with two weeks of fevers, chills, night sweats, and back pain. Computed tomography (CT) scan demonstrated aortitis with periaortic abscess. There was concern for BCG aortitis given the antecedent BCG exposure and prior BCGosis. Blood cultures were negative; AFB blood cultures were contaminated. A sample of plasma was sent to Karius (Redwood City, CA) for next-generation sequencing (NGS). Cell-free DNA was extracted and NGS performed. Human sequences were removed and remaining sequences were aligned to a curated pathogen database of >1,000 organisms. Organisms present above a statistical threshold were reported. The patient underwent surgical replacement of the infected endograft; endovascular samples were sent for AFB culture.ResultsPlasma-based NGS of cell free DNA detected M. tuberculosis (Mtb) complex at 48 hours (within 28 hours of sample receipt). Within the Mtb complex, the majority of sequences aligned to M. bovis with five reads aligning uniquely to M. bovis. No reads aligned to the region of deletion 1 (RD1) deleted in BCG. Surgical AFB cultures were positive for Mtb complex by PCR probe at nine days; Mtb complex was recovered in culture at 19 days.ConclusionPlasma metagenomic sequencing can be used to rapidly diagnose BCG-associated endovascular infection. Disclosures C. Cooper, Karius, Inc.: Consultant, Consulting fee. D. Hong, Karius, Inc.: Employee, Salary. L. Blair, Karius: Employee, Salary. S. Bercovici, Karius, Inc.: Employee, Salary. A. Ahmed, Karius, Inc.: Employee, Salary.

Atrophy of skin-draining lymph nodes predisposes for impaired immune responses to secondary infection in mice with chronic intestinal nematode infection.

Intestinal nematodes suppress immune responses in the context of allergy, gut inflammation, secondary infection and vaccination. Several mechanisms have been proposed for this suppression including alterations in Th2 cell differentiation and increased Treg cell suppressive function. In this study, we show that chronic nematode infection leads to reduced peripheral responses to vaccination because of a generalized reduction in the available responsive lymphocyte pool. We found that superficial skin-draining lymph nodes (LNs) in mice that are chronically infected with the intestinal nematode Heligmosomides polygyrus, do not reach the same cellularity as worm-free mice upon subsequent BCG infection in the skin. B cells and T cells, all declined in skin-draining LN of H. polygyrus-infected mice, resulting in LNs atrophy and altered lymphocyte composition. Importantly, anti-helminthic treatment improved lymphocyte numbers in skin-draining LN, indicating that time after de-worming is critical to regain full-scale LN cellularity. De-worming, and time for the skin LN to recover cellularity, also mended responses to Bacille Calmette-Guerin (BCG) in the LN draining the footpad injection site. Thus, our findings show that chronic nematode infection leads to a paucity of lymphocytes in peripheral lymph nodes, which acts to reduce the efficacy of immune responses at these sites.

Bacille Calmette–Guerin lymphadenitis in infants: A lesser known entity – Report of two cases

Bacille Calmette–Guerin (BCG) vaccine containing live-attenuated Mycobacterium bovis was first used in humans to prevent tuberculosis (TB) in 1921. Intradermal BCG vaccine gives rise to classic primary complex that consists of a cutaneous nodule at the site of injection and subclinical involvement of the regional lymph nodes, which is self-limiting and requires no treatment. BCG lymphadenitis is the most common complication of BCG vaccination. Fine-needle aspiration is the rapid, safe, and cost-effective method for diagnosis as well as the management of BCG lymphadenitis. Awareness of this lesser known entity is important to prevent misdiagnosis. We report two cases of 2½ month and 6-month healthy male infants with left axillary lymphadenopathy following BCG vaccination. Fine-needle aspiration from both the cases revealed features of necrotizing granulomatous lymphadenitis with Ziehl-Neelsen stain for acid-fast bacilli being positive in 2nd case. Ipsilateral regional lymph node enlargement following BCG vaccination is considered as the most common complication, some progress to suppuration. Very rarely disseminated BCG infection may develop in immune-compromised individuals, resulting in a devastating outcome. Variable strategies have been applied in treating lymphadenitis related to BCG vaccine in the past decade, ranging from observation, antimycobacterial therapy, aspiration, incision, and drainage to lymph node surgical excision.

INTRA-VESICAL BCG INDUCED GRANULOMATOUS HEPATITIS AND DISSEMINATED KOCH’S: OUR EXPERIENCE

Bacille Calmette-Guerin (BCG) vaccine, developed by Calmette and Guerin at Institute Pasteur (Lille, France), is a live-attenuated Mycobacterium bovis strain. There are many therapeutic uses of the species have been described, Intravesical BCG has been established as an effective treatment of superficial bladder cancer. A 66-year old gentleman with newly diagnosed superficial high-grade papillary transitional cell carcinoma involving lamina propria (T1) of the bladder underwent 3 cycles of intravesical BCG. First 2 cycles were uneventful and tolerated well. After 3rd BCG cycle, patient developed granulomatous hepatitis with disseminated Koch's. BCG-induced sepsis after intra-vesical instillation for bladder cancer is a rare complication. Pathophysiology remains largely unknown, but BCG’s low virulence suggests that immunological hypersensitivity reaction probably plays a role. There have been no prospective studies to evaluate the optimal treatment for BCG infection. Keywords: Bacille Calmette-Guerin (BCG), Mycobacterium bovis strain, granulomatous hepatitis.

Mouse BMDC-dependent T Cell Polarization Assays

In response to exposure to antigen, T cells whose T cell receptor (TCR) are capable of recognizing the self MHC-antigen derived peptide complex, respond to the antigen and differentiate into one of several subsets, namely TH1, TH2, TH17, Treg, etc. characterized by the signature cytokine they secrete, namely IFN-γ, IL-4, IL-17 or IL-10, respectively, referred to as syngeneic polarization as the MHC presenting the foreign antigen/epitope is self-derived. T cell responses following incubation for defined periods, usually 3 days for mouse splenocytes, are routinely measured by assessing the antigen-stimulated proliferation of T cells by measuring the radiolabeled precursor thymidine incorporated into the genomic DNA of the dividing T cell; the direction of polarization is assessed by measuring the cytokine produced by the proliferating or non-proliferating responding T cells using ELISA of culture supernatants or by intracellular cytokine staining followed by flow cytometry. In the protocols detailed below, we describe the use of syngeneic mouse bone marrow-derived primary dendritic cells (BMDC) as APC to stimulate spleen derived T cells. The proliferative response of the T cells is measured by incorporation of radiolabeled precursor thymidine into the genomic DNA and their direction of polarization is assessed by measuring the cytokines they secrete, namely IFN-γ, IL-4 and IL-17 over a 72 h period using ELISA. In addition, we used flow cytometry after intracellular cytokine staining to detect IL-17 positive T cells within the CD3+/CD4+/CD25low population. Prior live infection of BMDC with strains of Mycobacterium bovis- Bacille Calmette Guerin (BCG) was used as antigen to pre-condition the BMDC that presented antigens derived therefrom to T cells. We also measured cytokines secreted within 6 to 8 h of BCG infection by BMDC in order to correlate the BMDC cytokine profile with subsequent direction of T cell polarization.

BCGitis and BCGosis in children with primary immunodeficiency - imaging characteristics.

When administered to an immune-compromised patient, BCG (Bacille Calmette-Guérin) can cause disseminated and life-threatening infections. To describe the imaging findings in children with primary immunodeficiency and BCG-related infections. We reviewed the imaging findings of children with primary immunodeficiency treated at a children's hospital during 2012-2014 with localized or disseminated BCG infection. Imaging modalities included US, CT and radiography. Nine children with primary immunodeficiency had clinical signs of post-vaccination BCGitis; seven of these children showed disseminated disease and two showed only regional lesions with characteristic ipsilateral lymphadenopathy. Overall, lymphadenopathy was the most prevalent feature (n = 8) and characteristically appeared as a ring-enhancing hypodense (CT) or hypoechoic (US) lesion. Visceral involvement with multiple abscesses appeared in the spleen (n = 2), liver (n = 1) and bones (n = 1). All lesions regressed following appropriate anti-tuberculosis treatment. BCG infection needs to be considered in children with typical findings and with suspected primary immunodeficiency.

Adverse reactions to Mycobacterium bovis bacille Calmette-Guérin vaccination against tuberculosis in Iranian children.

PurposeThere are considerable variations in the number of adverse reaction reports related to vaccine from different countries. The aim of this study was to review the development of adverse reactions to bacille Calmette-Guérin (BCG) vaccination among hospitalized patients in an Iranian referral hospital.Materials and MethodsWe identified hospitalized patients with BCG complications in Pediatric Infectious Disease Research Center, Tehran University of Medical Sciences, Tehran, Iran during January 2007-April 2009. Data on demographics, clinical features, laboratory findings, personal history (including vaccination history), family history, and outcomes were retrieved from medical records.ResultsThere were 46 cases with BCG complication during the 2 years period. All of the children received vaccination at birth. Twenty-eight patients (61%) were male. The mean age of the patients was 13.5 ±11.3 months (range, 1 to 52 months; median, 10 months). The majority of children (57%) with BCG complication were less than 1 year old. Among hospitalized patients due to BCG complications, suppurative lymphadenitis was occurred in 28 children (61%) and lymphadenopathy was seen in 9 children (20%). Disseminated BCG was detected in 8 patients (17%) and only 1 child (2%) was presented with abscess. In 7% (n = 3) of children, the family history of BCG complications were positive.ConclusionThe most common side effect of the BCG vaccine in our study was suppurative lymphadenitis. Disseminated BCG infection in complications leading to hospitalization in our study was 17%. With regard to the difficulty in implementing such a guideline in settings where BCG is given to all newborns, registration of Iranian primary immunodeficiency disorders (PID) patients would be helpful to increase the awareness of medical community of Iran to investigate underlying disease. In addition, BCG vaccination should postpone in each newborn with a family history of PID until the definite condition has been ruled out.

Crosstalk between human DC subsets promotes antibacterial activity and CD8+T‐cell stimulation in response to bacille Calmette‐Guérin

To date, little is known about the unique contributions of specialized human DC subsets to protection against tuberculosis (TB). Here, we focus on the role of human plasmacytoid (p)DCs and myeloid (m)DCs in the immune response to the TB vaccine bacille Calmette-Guérin (BCG). Ex vivo DC subsets from human peripheral blood were purified and infected with BCG expressing GFP to distinguish between infected and noninfected cells. BDCA-1+ myeloid DCs were more susceptible than BDCA-3+ mDCs to BCG infection. Plasmacytoid DCs have poor phagocytic activity but are equipped with endocytic receptors and can be activated by bystander stimulation. Consequently, the mutual interaction of the two DC subsets in response to BCG was analyzed. We found that pDCs were activated by BCG-infected BDCA-1+ mDCs to upregulate maturation markers and to produce granzyme B, but not IFN-α. Reciprocally, the presence of activated pDCs enhanced mycobacterial growth control by infected mDCs and increased IL-1β availability. The synergy between the two DC subsets promoted BCG-specific CD8+ T-cell stimulation and the role of BCG-infected BDCA-1+ mDCs could not be efficiently replaced by infected BDCA-3+ mDCs in the crosstalk with pDCs. We conclude that mDC–pDC crosstalk should be exploited for rational design of next-generation TB vaccines.

Penile tuberculosis following intravesical Bacille Calmette-Guérin immunotherapy

Bacille Calmette-Guérin (BCG) is an effective treatment for patients with superficial bladder cancer and bladder carcinoma in situ (CIS). It may cause side effects usually due to local and systemic inflammatory effects. We report a case of a male patient with non-invasive urothelial carcinoma of urinary bladder (Stage T1) who developed caseating granulomas on his glans penis as a complication of intravesical BCG immunotherapy. Though there are other reported cases of BCG dissemination noted in the literature, penile granuloma is rare. The first reported case was published in 1992 and since then only eleven cases are reported. It appears that both direct infectious processes and hypersensitivity reactions contribute to the clinical manifestations of a systemic BCG infection. Our case possibly represents a local infection of M bovis involving the glans penis.

Molecular microbiological investigation of post-vaccination bacille Calmette-Guérin infection in Iranian patients

The World Health Organization (WHO) has called for closer monitoring of bacille Calmette-Guérin (BCG) complications with specific efforts to distinguish BCG infection from tuberculosis. To detect the presence of BCG infection using clinical and microbiological approaches. Between 2006 and 2008, 32 cases, including 30 children with suspected BCG-related complications and two adults with local skin infections, were referred to our laboratory. The definitive identification of the isolates was based on phenotypic and molecular testing. The genotype profile of the isolates was determined to evaluate the relatedness of the cases. Molecular microbiological results confirmed the presence of infection due to Mycobacterium bovis BCG in 11 patients, of whom 9 were aged 2 months to 6 years and 2 were aged > 40 years. Molecular fingerprinting revealed that all isolates were genetically related to each other and to M. bovis BCG Pasteur 1173P2. A high incidence of adverse reactions to the BCG vaccine in the population studied clearly points to the need for a thorough study on the issue. We hope our study will be viewed as an evidence-based document for more precise risk-benefit evaluation of BCG immunisation in immunocompromised patients.

Late bacille Calmette–Guérin infection with a large focal urinary bladder ulceration as a complication of bladder cancer treatment

• To report a late bacille Calmette-Guérin (BCG) complication previously not described in the literature. • We reviewed our database with 858 patients treated with BCG from 1986 to 2008 and identified 13 male patients (1.8% of all male patients) who had a large tuberculous-like bladder ulcer. • All patients had high-grade tumours and seven had tumours invading lamina propria before BCG treatment. A solitary ulceration or inflammatory lesion, 10-50 mm in diameter, was seen at routine follow-up cystoscopy 2-34 months (median 8 months) after the first instillation. Significantly more patients had been treated with BCG-RIVM than with BCG-Tice (10/320 vs. three of 454, P < 0.01). BCG was cultured from urine 3-34 months (median 14 months) after the last instillation. • So far, eight patients have been successfully treated with rifampicin and isoniazid. Nine patients are still tumour-free 15-66 months (median 44 months) after the last transurethral resection before BCG treatment. • Another three patients had one to two non-invasive recurrences. One patient had an invasive recurrence and underwent cystectomy. The present study is limited by biases associated with its retrospective design. • This is the first report on persisting BCG infections with large inflammatory lesions in the bladder. Treatment is effective and the oncological outcome is good. • Mycobacterial cultures of the urine should be performed in BCG-patients with unclear inflammatory lesions in the bladder since a delayed diagnosis of a persistent BCG infection could result in a permanently reduced bladder capacity. • Large studies are warranted to study differences in efficacy and side-effects between different BCG strains.